What Is Bowel Incontinence? What Is Fecal Incontinence? What Causes Bowel Incontinence?

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Main Category: GastroIntestinal / Gastroenterology
Also Included In: Crohn's / IBD;  Irritable-Bowel Syndrome
Article Date: 29 Sep 2009 - 8:00 PDT

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Bowel incontinence, also known as fecal (UK: faecal) incontinence, is an inability to control bowel movements. The person's stools (feces) leak from the rectum uncontrollably. Bowel incontinence can vary in severity from passing a small amount of feces when breaking wind, to total loss of bowel control.

Bowel incontinence is a sign or symptom of a condition or disease; it is not a condition or disease in itself. Generally, bowel incontinence is not life-threatening and does not impact negatively on the patient's health. However, the sufferer's quality of life, emotional and mental health, as well as self-esteem can be affected.

Just because people do not talk about bowel incontinence much does not mean it is not common. Approximately 1% of all adults in England have regular episodes of bowel incontinence. According to the American College of Gastroenterology, over 5.5 million Americans have bowel incontinence. People of all ages and both sexes can be affected. Bowel incontinence is significantly more common among elderly individuals, and is slightly more prevalent in females than males. Experts believe bowel incontinence is more common among women because it is a complication of pregnancy.

Health professionals in Europe, North America, and some other countries say that bowel incontinence is undertreated. In the UK only about 20% of people with some level of bowel incontinence report their symptoms to their doctors. This is probably because of:

• Embarrassment


• A belief among lay people that it is untreatable and they have to put up with it. This is a pity because bowel incontinence is usually treatable.


• A belief that bowel incontinence is a normal part of growing old. Again, with the right treatment people can usually maintain normal bowel function throughout their lives. Bowel incontinence is not a normal part of aging.


• A belief that the problem will eventually go away. In a small number of cases this is true. However, most people will require treatment.

What are the signs and symptoms of bowel incontinence?

Accidents or fecal leakage should not happen to adults, except when experiencing severe diarrhea. Individuals with chronic fecal incontinence may have few or regular accidents. Symptoms may vary from an inability to hold in gas, silent leakage of feces during daily activities or exertion, or not being able to get to the toilet in time.

There are commonly two terms used when referring to bowel incontinence:

• Urge bowel incontinence - the individual has a sudden urge to go to the toilet but is unable to get there in time.


• Passive soiling - nothing is felt to indicate that a bowel movement is about to occur.

The type of stools passed when an episode of bowel incontinence occurs can vary:

• The person may break wind while at the same time pass a small piece of stool.
• The stools may be liquidy.
• The stools may be solid.

Episodes of bowel incontinence can occur:

• Every day
• Every week
• Monthly

Other signs and symptoms that may accompany bowel incontinence:

• Abdominal cramping
• Abdominal pain
• Bloating
• Constipation
• Diarrhea
• Flatulence
• The anus is irritated
• The anus is itchy
• Urinary incontinence

For some individuals fecal incontinence is a relatively small problem, which results in the occasional soiling of underwear. For others, however, there may be a total lack of bowel control and the condition can be devastating.

What are the risk factors of bowel incontinence?

A risk factor is something that increases a person's chances of developing an illness, condition or set of symptoms. For example, being obese raises the risk of developing diabetes type 2; therefore obesity is a risk factor for diabetes type 2. Below are some known risk factors for bowel incontinence:

• Nerve damage - people with multiple sclerosis, long-term diabetes, or other conditions where the nerves that control defecation are damaged have a higher risk of developing fecal incontinence.


• Gender - fecal incontinence is more common among women than men, mainly because it is a possible complication of childbirth.


• Alzheimer's disease - people in late-stage Alzheimer's disease are more likely to have fecal incontinence because of the dementia linked to Alzheimer's, as well as nerve damage.


• Physical disability - an individual with a physical disability may find it harder to get to a toilet in time. A problem with dexterity may mean the person cannot get undressed in time.

What are the causes of bowel incontinence?

How do the bowels work?

As soon as our food is digested the remaining waste material - stools - moves towards the rectum (rectum instestinum). The rectum is a tube that links the intestines to a person's anus - it is the final part of the large intestine. The rectum is a temporary storage facility for feces - i.e. where our body stores poop before expelling it.

As the rectum fills up with stools the rectal walls expand. Stretch receptors (nerves) in the rectal walls stimulate the desire to defecate. If the person does not respond to that urge (if they do not defecate when there is an urge) the stools are often returned to the colon where more water is absorbed.

When the rectum is full the increased pressure forces the walls of the anal canal apart, allowing feces to enter the canal. The rectum shortens as material is forced into the canal and peristaltic waves propel the stools out of the rectum. The internal and external sphincters allow the stools to be passed by muscles pulling the anus up over the exiting feces.

The internal sphincter works automatically, while the external sphincter responds when we want it to.

Below are some possible causes of bowel incontinence:

• The sphincter muscles are not working as they should - damage to the sphincter muscles is commonly caused by childbirth (labor). The sphincter muscles can become stretched and torn, especially if forceps are used during delivery, or if the mother had an episiotomy. A complication of bowel or rectal surgery can also result in damage to the sphincter muscles. Some other types of injuries may also damage them.


• Diarrhea - if a person has diarrhea it is much more difficult for the rectum to hold the stools. Patients with recurring diarrhea often experience bowel incontinence. Chronic or recurring diarrhea can be caused by Crohn's disease, irritable bowel syndrome (IBS) and ulcerative colitis. These conditions sometimes result in scarring in the rectum, another cause of bowel incontinence.


• Certain foods - susceptible people may find that certain foods cause diarrhea and worsen their fecal incontinence symptoms. Examples may include spicy foods, fatty/greasy foods, cured meats, smoked meats, and dairy products if you are lactose intolerant.


• Some drinks - drinks containing caffeine may act as laxatives, as can those with artificial sweeteners.


• Constipation can also lead to bowel incontinence - if the solid stool becomes stuck (fecal impaction) the muscles of the rectum can become stretched and weaker, watery stools may then leak around the impacted stool and seep out of the anus. Fecal impaction is a large mass of dry hard stool that gets stuck in the rectum - it is literally so hard that it cannot come out.


• Rectal cancer - tumors that develop within the rectum can cause bowel incontinence.


• Rectal prolapse - if the rectum drops down into the anus, bowel incontinence can occur.


• Rectocele - this is when the rectum protrudes through the vagina.


• Hemorrhoids - hemorrhoids can result in incomplete closure of the anal sphincter.


• Chronic laxative abuse - individuals who overuse laxatives for a long time have a much higher risk of developing bowel incontinence.

How is bowel incontinence diagnosed?

The patient's GP (general practitioner, primary care physician) will ask questions regarding symptoms, bowel habits, diet, medical history, lifestyle, etc. Even though it may feel embarrassing it is vital that the individual talk as openly, honestly and comprehensively as possible. The doctor is there to help you - he/she is also bound by an oath not to pass on what you say to anybody else. In order to find the best treatment, the health care professional needs access to as much information as possible.

The GP may examine the patient's anus and surrounding area for any damage. The area between the anus and the genitals (perineum) will be checked for hemorrhoids, infections and other conditions. A pin or probe may be used to examine this area of skin which helps the doctor determine whether there is any nerve damage.

The doctor may also do a DRE (digital rectal examination) . After putting on a sterilized glove the physician will insert a finger into the patient's anus and up into the rectum. A DRE can help determine whether the patient has:

• Constipation
• Tumors
• Muscle problems
• A rectal prolapse - the doctor asks the patient to bear down while feeling around inside.

The doctor may order further testing, and may refer the patient to a gastroenterologist (a doctor specialized in conditions and diseases of the digestive system) or a proctologist (a doctor specialized in conditions and diseases of the rectum and the anus).

• Endoscopy - a long, thin flexible tube with a light source and video camera at the end (endoscope) is inserted through the anus into the rectum. The doctor sees images on a screen. Endoscopy can help determine whether there is an obstruction, damage, or inflammation in the rectum. Some patients may be given a sedative beforehand - the procedure is not painful, but can feel awkward.


• Anal manometry - in this commonly used test, the doctor inserts a narrow, flexible tube into the patient's rectum via the anus. A balloon at the tip is then expanded. This test helps the doctor gauge how tight the patient's anal sphincter is, as well as measuring the sensitivity (nerves) and function (muscles) of the rectum.
  
  During a manometry the patient will be asked to squeeze, relax and push the rectum muscles at specific moments. The doctor may also ask the patient to try to push the balloon out of the rectum is if it were a stool.
  
  By varying the size of the balloon the physician can also find out when the rectum feels full. If the balloon is fairly large but the patient does not feel full down there it could mean that there is a problem with the nerves.


• Anorectal ultrasonography (ultrasound scan) - this test evaluates the structure of the sphincter. A narrow, wand-like device is inserted into the anus and rectum. The device emits sound waves which bounce off the walls of the rectum and anus, and produce video images of the internal structures.


• Defecography (protography) - the doctor uses a small amount of barium (a liquid) to coat the walls of the rectum. X-ray pictures are taken of the rectum. The patient drinks the barium. The barium shows up on the X-ray. The patient will be asked to pass a stool while the X-rays are taken. The test can determine how much stool the rectum can hold, and how well the stools are evacuated.


• Anal electromyography - tiny needle electrodes are inserted into the muscle around the anus. A light electrical current is sent through the electrodes into the muscles and nerves in the area. A computer, which is attached to the electrodes, can track how the electrical signals are transmitted through the muscles and nerves. The test checks whether there is any damage to the nerves running from the rectum to the brain. If the computer detects a delay in the transmission of the electrical signals it can locate where the nerve damage is.

What are the treatment options for bowel incontinence?

Most treatments for bowel incontinence can help restore bowel control, or at least significantly reduce its severity.

• Medications
  
  
  • Anti-diarrheal medications - examples include loperamide (Imodium) which helps treat diarrhea. Loperamide can rarely have side effects - when they do occur they can be serious. Any patient taking loperamide and experiences any of the following side effects should tell their doctor immediately:
    
    
    Serious irritation, blistering or reddening of the mouth, genitals or skin
    Severe constipation
    Swelling of the face
    Swelling of the lips
    Swelling of the throat
    Swollen stomach
    
    
    If you feel drowsy or dizzy you should not drive or operate heavy machinery.
  
  
  • Laxatives - if the individual's chronic constipation is causing incontinence the doctor may recommend short-term use of laxative. Milk of magnesia is an effective constipation medication and can help restore normal bowel function.
    
    Bulk-forming laxatives help the stools retain fluid, so they are less likely to become dry. Stools should be denser and softer, resulting in easier defecation. The following bulk-forming laxatives may be prescribed: ispaghula husk, methylcellulose, and sterculia. Patients should make sure they drink plenty of liquids. Effects will usually become noticeable after two to three days. Do not take them before going to bed.
    
    Other medications that decrease bowel motility, or decrease water content in the stool may also be recommended.


• Dietary changes - bowel incontinence linked to diarrhea or constipation may sometimes be controlled if the patient changes his/her diet. The patient may be asked to keep food diary so that diet changes can be monitored for their impact.
  
  If chronic constipation is causing bowel incontinence the doctor may ask the patient to drink more fluids and consume more fiber-rich foods.
  
  If diarrhea is contributing to the incontinence an increase in high-fiber foods that add bulk to the stools may be recommended.


• Bowel training - patients with lack of sphincter control or low awareness of the urge to defecate may find a bowel training program effective. It includes exercises which restore the strength of vital muscles for bowel control.
  
  Bowel training may involve learning to go to the toilet at certain times of the day, such as after a meal. If bowel movements occur at specific times each day it often becomes easier for the patient to regain control.


• Biofeedback - this is another type of bowel training. A pressure-sensitive probe is inserted into the anus. Every time muscles of the anal sphincter contract around the probe the device senses it and the patient can get a good idea of his/her muscle activity. By practicing muscle contractions and viewing their strength and response on a display, the patient can learn to strengthen those muscles.


• Stool impaction treatment - if laxatives or an enema did not solve the stool impaction problem the doctor may have to remove it. With two gloved fingers the physician breaks the stool into small pieces, making them easier to expel.


• Sacral nerve stimulation - four to six small needles are positioned in the muscles of the lower bowel. The muscles are stimulated by an external pulse generator which emits electrical pulses. If the patient responds well to this treatment a permanent pulse generator may be implanted under the skin of the patient's buttock. It looks much like a pacemaker. The sacral nerve runs from the spinal cord to muscles in the pelvis and is involved in bowel and urinary continence.


• Pelvic floor muscle training - this is commonly practiced by mothers after giving birth to treat cases of bowel and urinary incontinence. A physical therapist (UK: physiotherapist) teaches the patient a range of exercises which strengthen muscles that have been weakened and/or stretched during labor. Most women should perform the exercises several times a day for about two months.


• Enemas - these may be used when the incontinence is caused by fecal impaction and other treatments have not worked to expel the impacted stool. A small tube is placed into the anus and a special solution is inserted to wash out the rectum.


• Surgery - surgery is usually only an option if the patient has not responded to other treatments, or if there is an underlying condition causing incontinence that requires surgery.
  
  
  • Sphincteroplasty - this is surgery to repair a damaged or weakened anal sphincter. The surgeon removes damaged muscle, and muscle edges are overlapped and sewn back together, providing extra support to the muscles and tightening the sphincter.
  
  
  • Stimulated graciloplasty (gracilis muscle transplant) - the surgeon takes a small amount of muscle from the patient's thigh and uses it to create an artificial sphincter, i.e. the sphincter muscles are replaced with muscle from another part of the body. Electrodes attached to a pulse generator are inserted into the artificial sphincter. The impulses gradually change the way the muscles work. This procedure has a risk of infection, as well as complications caused by the pulse generator.
  
  
  • Sphincter replacement - the damaged anal sphincter is replaced with an inflatable cuff which is implanted around the anal canal. When it is inflated it keeps the anal sphincter firmly shut until the person is ready to defecate. A small external pump deflates the device allowing the stool to be released. The device then reinflates automatically about ten minutes later.
  
  
  • Surgery for a prolapsed rectum - a rectal prolapse occurs when a part of the rectum protrudes through the anus, weakening the anal sphincter. Surgical repair of the sphincter muscle may have to be done at the same time. This procedure is only done if other treatments to correct a rectal prolapse have not worked.
  
  
  • A rectocele - if the rectum protrudes into the vaginal wall surgery may be needed to correct fecal incontinence. A rectocele should only be treated if it causes significant symptoms.
  
  
  • Prolapsed internal hemorrhoids - these may prevent the anal sphincter from closing properly, resulting in bowel incontinence. These can be treated by conventional hemorrhoidectomy, a surgical procedure to remove them.
  
  
  • Colostomy - stools are diverted through a hole in the colon and through the wall of the abdomen. A special bag is attached to the opening to collect the stool. This procedure is considered as a last resort, when all else has failed.

How to prevent bowel incontinence

The following measures may help prevent bowel incontinence, or reduce the severity of symptoms:

• Avoid constipation - if your bowel incontinence is caused by chronic constipation you may find that getting more exercise, eating foods that are high in fiber, and consuming plenty of liquids may reduce your constipation, resulting in less bowel incontinence.


• Diarrhea - if you have diarrhea you may find that either treating or getting rid of its cause may help avoid episodes of unintentional defecation. For example, treating an infection in the digestive system may get rid of the diarrhea faster.


• Don't strain - when defecating if you overstrain you may weaken the anal sphincter muscles, which may increase your risk of developing bowel incontinence. So, don't strain.

Written by Christian Nordqvist
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today

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