Fecal incontinence

Definition

Fecal incontinence is the inability to control your bowel movements, causing stool (feces) to leak unexpectedly from your rectum. Also called bowel incontinence, fecal incontinence ranges from an occasional leakage of stool while passing gas to a complete loss of bowel control in someone who is older than 4 years old.

Common causes of fecal incontinence include constipation, diarrhea, and muscle or nerve damage. Fecal incontinence may be due to a weakened anal sphincter associated with aging or to damage to the nerves and muscles of the rectum and anus from giving birth.

Whatever the cause, fecal incontinence can be embarrassing. But don't shy away from talking to your doctor. Treatments are available that can improve, if not correct, fecal incontinence.

Symptoms

Generally, adults don't experience fecal incontinence except perhaps during an occasional short-lived bout of diarrhea. But that's not the case for people with recurring, or chronic, fecal incontinence. If you have fecal incontinence, you:

  • Can't control the passage of gas or stools, which may be liquid or solid, from your bowels
  • May not be able to make it to the toilet in time

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.

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. Often, new mothers and other adults are reluctant to tell their doctors about their fecal incontinence problems. But treatments are available, and the sooner you get evaluated, the sooner you may find some relief from your symptoms

Causes

A broad range of conditions and disorders can cause fecal incontinence, including:

  • Constipation. It's ironic, but a common cause of fecal incontinence is constipation. That's because chronic constipation may lead to impacted stool — a large mass of dry, hard stool within your rectum. This mass can be too large for you to pass, and as a result, the muscles of your rectum and intestines stretch, and then eventually weaken. Watery stool from farther up in the digestive system may move around the hard mass and leak out, causing fecal incontinence.

    Besides causing the muscles of your anus to stretch and weaken, chronic constipation may also make the nerves of the anus and rectum less responsive to the presence of stool in the rectum. Additionally, weakened muscles don't move stool as efficiently through the digestive system.

  • 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.
  • Muscle damage. Often, the cause of fecal incontinence is injury to the anal sphincter — the rings of muscle at the end of the rectum that help hold in stool. If these muscles are damaged, they're simply not strong enough to hold stool back properly, and some may leak out. This kind of damage can occur during childbirth, especially if you have an episiotomy or forceps are used during delivery.
  • Nerve damage. Fecal incontinence can be caused by damage to the nerves that sense stool in the rectum or to those that control the anal sphincter. Nerve damage can be caused by childbirth, constant straining during bowel movements, spinal cord injury or stroke. Diseases such as diabetes and multiple sclerosis also can affect these nerves and cause damage that leads to fecal incontinence.
  • Loss of storage capacity (accommodation) in the rectum. Normally, your rectum stretches to accommodate stool. If your rectum is scarred or your rectal walls have stiffened from surgery, radiation treatment or inflammatory bowel disease, such as Crohn's disease or ulcerative colitis, the rectum can't stretch as much as it needs to, so excess stool can leak out.
  • Surgery. Surgery to treat hemorrhoids — enlarged veins in the rectum or anus — can damage the anus and cause fecal incontinence, as can more-complex operations involving your rectum and anus.
  • Rectal cancer. Cancer of the anus and rectum can lead to fecal incontinence if the cancer invades the muscle walls or disrupts the nerve impulses needed for defecation.
  • Other conditions. If your rectum drops down into your anus (rectal prolapse) or, in women, if the rectum protrudes through the vagina (rectocele), fecal incontinence can result. Hemorrhoids may prevent complete closure of the anal sphincter, leading to fecal incontinence.

Risk factors

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

  • Increasing age. Although fecal incontinence can occur at any age, it's more common in older adults who sometimes have to cope with a lack of bladder control (urinary incontinence) as well. However, fecal incontinence is not a normal part of the aging process.
  • Being female. Fecal incontinence may be more common in women than in men because this condition can be a complication of childbirth.
  • Nerve damage. People who have long-standing diabetes or multiple sclerosis — conditions that can damage nerves that help control defecation — may be at risk of fecal incontinence.
  • 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, or the injury that caused a physical disability also may have caused rectal nerve damage that resulted in fecal incontinence.

Complications

Complications of fecal incontinence may include:

  • Emotional distress. Fecal incontinence can be a source of embarrassment and shame. It's not uncommon for someone with fecal incontinence to try to hide the problem or to avoid social engagements. The loss of dignity associated with losing control over one's bodily functions can lead to frustration, anger and depression.
  • Skin irritation. Besides the emotional aspects, fecal incontinence can irritate the skin. Because the skin around the anus is delicate and sensitive, repeated contact with stool can lead to pain, itching and can potentially lead to sores (ulcers) that require medical treatment.

Appointment

If you have fecal incontinence, you're likely to start by seeing your family doctor. However, in some cases, you may be referred immediately to a gastroenterologist.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready, and what to expect from your doctor.

What you can do

  • Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything special you need to do in advance.
  • Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Write down key personal information, including any major stresses or recent life changes.
  • Make a list of all medications, as well as any vitamins or supplements, that you're taking. Be sure to include the dose information as well.
  • Write down questions to ask your doctor.

Your time with your doctor may be limited, so preparing a list of questions will help you make the most of your time together. For fecal incontinence, some basic questions to ask your doctor include:

  • What is likely causing my symptoms?
  • Are there any other possible causes?
  • What kinds of tests do I need? Is any special preparation necessary?
  • Is my condition likely temporary or chronic?
  • What treatments can help? Which do you recommend?
  • I have these other health conditions. How can I best manage these conditions together?
  • Are there any dietary restrictions that I need to follow? Would changing my diet help?
  • Is there anything else I can do on my own that might help improve my symptoms?
  • Is there a generic alternative to the medicine you're prescribing me?
  • Are there any brochures or other printed material that I can take with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Have your symptoms been continuous or occasional?
  • How severe are your symptoms?
  • Do you avoid any activities because of your symptoms?
  • What, if anything, seems to improve your symptoms?
  • Does anything seem to make your symptoms worse?
  • 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?
  • 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.

Tests and diagnosis

Medical historyTo determine the cause of fecal incontinence, your doctor will ask you questions related to your condition — such as when and how often you experience an inability to control your bowels.

Physical exam In addition to talking with you, your doctor may also perform a physical examination. The exam usually includes a visual inspection of your anus and the area between your anus and genitals (perineum) for hemorrhoids, infections and other conditions. Your doctor may use a pin or probe to examine this area of skin. Normally this touching causes your anal sphincter to contract and your anus to pucker. This test helps your doctor check for nerve damage.

Medical tests A number of medical tests also are available to help pinpoint the cause of fecal incontinence. These may include:

  • 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 of the rectal area. During the exam, your doctor may ask you to bear down. Bearing down helps check whether rectal prolapse or certain other conditions exist.
  • Anal manometry. In this commonly used test, your doctor inserts a narrow, flexible tube into your anus and rectum. Once the tube is in place, a small balloon at the tip of the tube may be expanded. This test lets your doctor know how tight your anal sphincter is. It also measures the sensitivity and function of your rectum.
  • Anorectal ultrasonography. In this procedure, which evaluates the structure of your sphincter, your doctor inserts a narrow, wand-like instrument into your anus and rectum. This instrument, which is attached to a computer and video screen, emits sound waves. The waves bounce off the walls of your rectum and anus, producing video images of these internal structures.
  • Proctography. In this procedure, also known as defecography, your doctor uses a small amount of liquid called barium to coat the walls of your rectum. Barium makes your rectum more visible on X-rays, which are then taken. This test measures how much stool your rectum can hold. It also evaluates how well stool is evacuated from your rectum.
  • Proctosigmoidoscopy. In this test, your doctor uses a long, slender tube with a tiny video camera attached to examine your rectum and sigmoid — the lower portion of your colon. This test detects signs of inflammation, tumors or scar tissue that may cause fecal incontinence. Your doctor may also want to perform colonoscopy to see the entire colon.
  • Anal electromyography. This test involves the insertion of tiny needle electrodes into muscles around your anus that can reveal signs of nerve damage.

Treatments and drugs

A variety of treatments are available for fecal incontinence, depending on the severity of your symptoms. Treatment may include dietary changes, medications, special exercises that help you better control your bowels, or surgery.

Medications Sometimes, doctors recommend medications to treat fecal incontinence, such as:

  • Anti-diarrheal drugs. Your doctor may recommend medications to reduce diarrhea and help you avoid fecal incontinence. A drug called loperamide (Imodium) may be used because it helps treat diarrhea.
  • Laxatives. If chronic constipation is to blame for your incontinence, your doctor may recommend the temporary use of mild laxatives, such as milk of magnesia, to help restore normal bowel movements.
  • Stool softeners. To prevent stool impaction, your doctor may recommend a stool-softening medication.
  • Other medications. If diarrhea is the cause of your fecal incontinence, your doctor may recommend drugs that decrease the spontaneous motion of your bowel (bowel motility) or medications that decrease the water content of your stool.

Therapies A variety of therapies may improve fecal incontinence:

  • Dietary changes. What you eat and drink affects stool consistency. Your doctor may recommend changes to your diet to help improve your bowel movements.

    For example, if chronic constipation is to blame for fecal incontinence, your doctor may recommend that you drink plenty of fluids and eat fiber-rich foods. A fiber supplement may also be recommended. If diarrhea is contributing to the problem, your doctor may recommend that you increase your intake of high-fiber foods to add bulk to your stools, making them less watery. In general, your doctor will recommend a diet that helps you gain good stool consistency for increased control of your bowels.

  • Bowel training. If fecal incontinence is due to a lack of anal sphincter control or decreased awareness of the urge to defecate, you may benefit from a bowel-training program and exercise therapies aimed at helping you restore muscle strength.

    In some cases, bowel training means learning to go to the toilet at a specific time of day. For example, your doctor may recommend that you make a conscious effort to have a bowel movement after eating. This helps you gain greater control by establishing with some predictability when you need to use the toilet.

    Biofeedback is another bowel-training treatment for fecal incontinence. It involves inserting a pressure-sensitive probe into your anus. This probe registers muscle strength and activity of your anal sphincter as it contracts around the probe. You can practice sphincter contractions and learn to strengthen your muscles by viewing the scale's display. These exercises can strengthen your rectal muscles.

  • Treatment for stool impaction. Your doctor may have to remove an impacted stool if taking laxatives or using enemas doesn't help you pass the hardened mass. To remove an impacted stool, your doctor inserts one or two gloved fingers into your rectum to break apart the impacted stool. These smaller pieces are easier to expel.
  • Sacral nerve stimulation. Another treatment for fecal incontinence is sacral nerve stimulation. The sacral nerves run from your spinal cord to muscles in your pelvis. These nerves regulate the sensation and strength of your rectal and anal sphincter muscles. Sacral nerve stimulation is carried out in stages. First, small needles are positioned in the muscles of your lower bowel, and these muscles are stimulated by an external pulse generator to identify which muscle stimulates anal contractions the most. The muscle response to the stimulation generally isn't uncomfortable. After a successful response, you may have a permanent pulse generator implanted. This treatment is usually done only if other treatments haven't worked.

Surgery For some people, treatment of fecal incontinence requires surgery to correct an underlying problem. Surgical procedures to treat fecal incontinence aren't necessarily easy or free of complications. But, certain causes of fecal incontinence — anal sphincter damage caused by childbirth or rectal prolapse, for example — can often be effectively treated with surgery. Surgical options include:

  • Sphincteroplasty. This is surgery to repair a damaged or weakened anal sphincter. In this procedure, an injured area of muscle is identified and its edges are freed from the surrounding tissue. The muscle edges are then brought back and sewn together in an overlapping fashion. This strengthens the muscle, tightening the sphincter.
  • Treating rectal prolapse, a rectocele or hemorrhoids. If you have other problems, such as a condition in which a portion of your rectum protrudes through your anus (rectal prolapse), a protrusion of the rectum into the vaginal wall (rectocele) or hemorrhoids that are causing fecal incontinence, surgical correction of these problems will likely reduce or eliminate your fecal incontinence.
  • Sphincter replacement. An artificial anal sphincter can be used to replace a damaged anal sphincter. The device is essentially an inflatable cuff, which is implanted around your anal canal. When inflated, the device keeps your anal sphincter shut tight until you're ready to defecate. To go to the toilet, you use a small external pump to deflate the device and allow stool to be released. It then reinflates itself.
  • Sphincter repair. During a surgical procedure called a gracilis muscle transplant, a muscle is taken from your inner thigh and wrapped around your sphincter. This restores muscle tone to your sphincter.
  • Injection of biomaterials. Injection of a silicone-based material into the anal sphincter may improve incontinence by increasing the size of the anal sphincter. Other types of biomaterials are under study.
  • Colostomy. As a last resort, a colostomy may be the most definitive way to correct fecal incontinence. Colostomy is generally considered only after other treatments have failed. A colostomy is an operation that diverts stool through an opening in the abdomen. A special bag is attached to this opening to collect the stool.

Home remedies

Kegel exercisesKegel exercises strengthen the pelvic floor muscles, which support the uterus, bladder and bowel, and may help reduce incontinence. To perform Kegel exercises, contract the muscles that you would normally use to stop the flow of urine. Then, hold the contraction for three seconds, and then relax for three seconds. Repeat this pattern 10 times. As your muscles get stronger, hold the contraction longer, gradually working your way up to three sets of 10 contractions every day.

Dietary changes If fecal incontinence is due to a problem that can't be completely corrected with exercises, medications, bowel training or surgery, you may still be able to gain better control of your bowel movements. You can start by making changes in your diet:

  • Keep track of what you eat. Make a list of what you eat for a week. You may discover a connection between certain foods and your bouts of incontinence. Once you've identified which foods are problems for you, 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, cured or smoked meat, carbonated beverages, 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.
  • Eat smaller meals. Try to eat several small meals throughout the day, rather than three large ones, because large meals sometimes trigger bowel contractions that may cause diarrhea.
  • Get adequate fiber. Fiber helps makes stool soft and easier to control. Fiber is present in fruits, vegetables, and whole-grain breads and cereals. Aim for 20 to 30 grams of fiber a day, 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 In addition to managing fecal incontinence through changes to your diet, you can help avoid further discomfort 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 — you can do this by using wet toilet paper. Showering or soaking in a bath may also help. Soap can dry and irritate the skin. So can rubbing with dry toilet paper. Pre-moistened, alcohol-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. Ask your doctor to recommend a product. 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 better manage the problem. You can purchase incontinence products at drugstores, supermarkets and medical supply stores. If you use pads or adult diapers, be sure they have an absorbent wicking layer on top. Products with this layer wick moisture away from your skin.

Coping and support

If you have fecal incontinenceIf you have fecal incontinence, you may not want 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 cleanup supplies and a change of clothing with you.
  • Know where toilets are before you need them so that you can get to them quickly.

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. If you haven't been to a doctor yet, make an appointment.

If you're caring for someone who has fecal incontinence If you care for someone with fecal incontinence, try to be supportive. In addition:

  • Take your loved one to the doctor to see what treatment options are available.
  • Take him or her to the toilet regularly.
  • Make sure clothing can be easily removed.
  • Place a commode near the bed.
  • Put washable cushions or slipcovers on furniture.
  • At night, have your loved one use absorbent undergarments and put washable pads on the bed.

Prevention

It may be possible to prevent fecal incontinence, depending on the cause. These actions may help:

  • Reduce constipation. Fecal incontinence due to chronic constipation can be improved or eliminated by treating the constipation. Getting more exercise, eating high-fiber foods and drinking plenty of fluids are generally advised to avoid constipation.
  • Control diarrhea. If diarrhea is to blame, 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 eventually may weaken anal sphincter muscles or damage nerves and, at times, lead to fecal incontinence, so avoid straining when possible.

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