What is fecal incontinence?
Fecal incontinence is when a person loses the ability to control their bowel movement, resulting in leakage of gas or stool (feces) through the anus (back passage). It can range from difficulty with control of gas to more severe with loss of control over liquid or formed stool. It is a common problem, which can affect up to 1 in 10 people at some time in their lives. They may have bowel accidents that are caused by not being able to get to a toilet quickly enough (urge leakage), or they may experience soiling or leaking from the bowel without being aware of it (passive leakage).
Fecal incontinence can have many different causes. It can be distressing and can severely affect everyday life. Many people with fecal incontinence find it very difficult and embarrassing to talk about with doctors and nurses, or to tell their family and friends. However, once fecal incontinence has been identified there are treatments that can help manage or sometimes cure it, as well as strategies to help people cope with the condition and discuss it openly.
How does a normal bowel work?
Normal bowel frequency is between three times a day and two times a week, but most people open their bowels once a day. Normal consistency of stools should be soft and formed. Normally the bowel and rings of muscle around the back passage (anal sphincter) work together to ensure that bowel contents are not passed until we are ready. The sphincter has two main muscles which keep the anus closed: the inner (internal anal sphincter) ring, which keeps the anus closed at rest, and the outer (external anal sphincter) ring, which provides extra protection when the urge to open the bowel is felt and when we exert ourselves, cough or sneeze (Figure 1). These muscles, the nerves supplying them and the sensation felt within the bowel and sphincter all contribute to the sphincter remaining tightly closed. This balance enables us to stay in control (or ‘continent’).
When stool enters the rectum the internal anal sphincter muscle automatically relaxes and opens up the top of the anal canal. This allows the sensitive nerves at the top of the anal canal to detect whether it is wind, watery stool or normal stool. The external anal sphincter can be deliberately squeezed to delay bowel emptying if it is not convenient to find a toilet. Squeezing the external sphincter pushes the stool out of the anal canal and back into the rectum, where the stool is stored until a convenient time.
What causes fecal incontinence?
Fecal incontinence occurs most commonly because the anal sphincter is not functioning properly. Damage to the sphincter muscles or to the nerves controlling these muscles, decreased muscle strength, excessively strong bowel contractions, or alterations to bowel sensation can all lead to this disturbance of function.
One of the most common causes of fecal incontinence in women is an injury during childbirth. The anal muscle may be torn during delivery or there may be damage to the nerves that help the anal muscle function. Some of these injuries can be recognized at the time of delivery, but others may not be as obvious and not become a problem until later in life.
Who is at risk of fecal incontinence?
There are certain groups of people who are more likely to have fecal incontinence than others. Healthcare professionals should ask people (or their carers) whether they experience fecal incontinence if they are in one of the following groups:
- Following childbirth – usually due to a tear (hidden or obvious) in the sphincter muscles
- People of any age who experience an injury or infection of the sphincter; they may be affected immediately or later in life
- People suffering from Inflammatory Bowel Disease (colitis) or Irritable Bowel Syndrome (alternating diarrhea and constipation together with abdominal pain) because the bowel is very overactive and squeezes strongly
- People who have had an operation on their colon (part of the bowel) or anus
- People who have had radiotherapy to their pelvic area
- People who have had a prolapse of their rectum or organs in their pelvis (this means that these organs have slipped down from their usual position in the body)
- People who have an injury to or disease of their nervous system
- People with learning disabilities or memory problems
- Children and teenagers – if they are born with an abnormal sphincter or if they have persistent constipation
- Frail elderly people
- People with urinary incontinence
What are the treatment options?
Your bowels are a part of your body and it is possible to get back in control of them. This may seem difficult at times, especially when you feel under stress. You may need advice from a specialist who has expert knowledge about fecal incontinence. These problems are common so you need not feel embarrassed about discussing them. Most of the treatments are simple and effective, so do not hesitate to seek advice.
The following measures will help you towards regaining control.
Diet / bowel habits
Changes to diet and bowel habit can be helpful for many people because the type of food you eat and the amount of fluid you drink can help with regular bowel movements and the firmness of your stools. You may be asked to keep a diary of your food and fluid intake so that any changes can take into account your current diet. Any changes should also consider particular dietary needs that you may have. You should eat a healthy balanced diet and drink between 1.5-2 litres of fluid per day (6-8 cups full). Water and squash are best and caffeinated drinks should be kept to a minimum. It is worth experimenting with your diet to see if certain foods worsen the situation. In particular, an excessive high fibre diet (too much bran, cereal, fruit, etc.), too much caffeine or alcohol and a lot of artificial sweeteners can worsen fecal incontinence.
Access to the toilet
A very important way of managing your incontinence is to make sure you can use the toilet as easily as possible. You should be given advice about clothing that is easy to remove so that you can use the toilet more quickly. A healthcare professional may assess your home and your mobility to see what extra help or equipment you might need to help you get to the toilet. If you are in a hospital or a care home, toilets should be easy to find and help to use the toilet should be available if you need it. Your privacy and dignity should always be respected.
Anyone who has frequent bowel motions, diarrhea or accidental fecal leakage may get sore skin around the back passage. This can be very uncomfortable and distressing. Occasionally, the skin may become so inflamed that it breaks into open sores. These sores can be difficult to heal. Taking good care of the skin around your back passage can help to prevent these problems from developing.
Pelvic Floor / Anal Sphincter Exercises
The pelvic floor is a sheet of muscles that extend from your tail bone (coccyx) to your pubic bone at the front, forming a “platform” between your legs. They support the bladder, bowel and uterus (in women). The pelvic floor muscles help to control when you pass urine and open your bowels. Pelvic floor muscle exercises to improve the coordination and strength of the pelvic muscles can improve or stop any leakage from your bowels. If you opt for pelvic floor muscle exercises, a trained healthcare professional should plan a programme with you, including regular assessment of your symptoms to see how well the exercises are going.
Special exercises to strengthen the anal sphincter muscles help many people. Techniques such as biofeedback are now available to re-train the bowel to be more sensitive to the presence of stool, so that the sphincter contracts when necessary and they are used in conjunction with physical treatments to improve bowel and pelvic floor coordination. In addition, electrical stimulation involving the application of tiny, safe electric currents to the anus in order to improve coordination and strength may also be added to the treatment.
Sacral nerve stimulation
This is a way of using electrical pulses to keep the anal sphincter closed. It is only suitable for people who have a weak but intact sphincter. It involves inserting electrodes under the skin in the lower back and connecting them to a pulse generator (Figure 4). This system produces pulses of electricity that are thought to affect the nerves controlling the lower part of the bowel and the anal sphincter, with the result that a person does not pass feces until he or she is ready to do so. There have been reports of good success with this method, 2 to 3 out of 4 people (50 – 75%) improved or had no leakage. There was also evidence that people’s quality of life was improved once the sacral nerve stimulation system was in place.
If your doctor thinks surgery might help you, he or she should refer you to a specialist surgeon. The surgeon should discuss the possible options with you, explaining the risks and benefits and how likely the operation is to work. The type of operation offered will depend on what is causing your incontinence. For example, if you have a gap in your anal sphincter you may be offered an operation to repair it. When there is nerve damage to sphincter muscles a different operation to tighten the sphincter will sometimes help. Depending on your condition, the specialist will discuss the various surgical options with you. If you decide to have one of the operations, you should be offered ongoing support to help you.