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Fecal Incontinence

Fecal incontinence, commonly referred to as bowel control problems, is the inability to hold a bowel movement until reaching a bathroom. FI also refers to the accidental leakage—for example, while passing gas—of solid or liquid stool. Feces is another name for stool.

Fecal incontinence is one of the most psychologically and socially debilitating conditions in an otherwise healthy individual. It can lead to social isolation, loss of self-esteem and self-confidence, and depression. Among people over age 65, most surveys find that women experience bowel incontinence more often than men. One to three out of every 1,000 women report a loss of bowel control at least once per month. 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. 

Why does Fecal Incontinence Occur?

Bowel function is controlled by 3 things: anal sphincter pressure, rectal sensation and rectal storage capacity. The anal sphincter is a muscle that contracts to prevent stool from leaving the rectum. This muscle is critical in maintaining continence. Rectal sensation tells a person that stool is in the rectum and that it is time to go to the bathroom. The rectum can stretch and hold stool for some time after a person becomes aware that the stool is there. This is the rectal storage capacity.

A person also must be alert enough to notice the rectal sensation and do something about it. He or she must also be able to move to a toilet. If something is wrong with any of these factors, then fecal incontinence can occur.

Who gets Fecal Incontinence?

Nearly 18 million U.S. adults—about one in 12—have FI. FI  is not always a part of aging, but it is more common in older adults. FI is slightly more common among women.

Having any of the following can increase the risk of FI:

  • Diarrhea

  • A disease or injury that damages the nervous system

  • Poor overall health—multiple chronic illnesses

  • A difficult childbirth with injuries to the pelvic floor—the muscles, ligaments, and tissues that support the uterus, vagina, bladder, and rectum  

What are the Different Types of Fecal Incontinence?

Flatal Incontinence - the inability to control the passage of gas from the rectum

  • Fecal Incontinence - the inability to control the passage of liquid or solid stool from the rectum

  • Double Incontinence - the inability to control both the passage of stool from the rectum and urine from the urethra (the tube through which urine normally goes through)

  • Rectovaginal Fistula -  Occurs when a connection develops between the vagina and rectum and results in stool being passed uncontrollably through the vagina

What Causes Fecal Incontinence?

Continence requires the normal function of both the lower digestive tract and the nervous system. The anal sphincters, along with the pelvic muscles that surround the end of the digestive tract, ensure controlled movement of digestive tract contents. There are many possible causes of fecal incontinence; in most cases, incontinence results from some combination of these causes.

  • Damage to the anal sphincters — The internal and external anal sphincters are the muscles located at the end of the rectum. These muscles and the surrounding pelvic muscles create a barrier that prevents the escape of feces. Any damage to or loss of control over these sphincters can lead to incontinence. Damage most commonly occurs during vaginal childbirth and anal surgery.

  • Neurologic Causes — Neurologic disorders such as diabetes, multiple sclerosis, and spinal cord injury can decrease sensation and control over the lower digestive tract. Nerve damage during vaginal childbirth can also decrease anal sphincter function.

  • Decreased Distensibility of the Rectum — Conditions such as inflammatory bowel disease (eg, Crohn's disease and ulcerative colitis) and radiation-induced inflammation of the rectum (radiation proctitis) can impair the rectum's ability to expand and store fecal matter.

  • Fecal Impaction — When hardened feces accumulates in the rectum, this can cause the anal sphincters to relax and allow liquid stool to escape around the blockage. Fecal impaction is a common cause of incontinence in older adults. Factors that make impaction more likely include certain mental health conditions, immobility, and loss of rectal sensation.

  • Diarrhea — Diarrhea of various causes, including irritable bowel syndrome, active inflammatory bowel disease, or acute gastroenteritis, can lead to loss of liquid stool. In some cases, if the diarrhea is treated, the person will be able to control their incontinence.

  • Unknown Causes — In some cases, the cause of fecal incontinence cannot be identified; this is called idiopathic incontinence. Idiopathic incontinence most commonly occurs in middle-aged and older women

How is Fecal Incontinence Diagnosed?

Doctors understand the feelings associated with fecal incontinence, so you can talk freely with your doctor. The doctor will ask some health-related questions, do a physical exam, and possibly run some medical tests. Your doctor may refer you to a specialist, such as a gastroenterologist, proctologist, or colorectal surgeon.

The doctor or specialist may conduct one or more tests:

Anal manometry checks the tightness of the anal sphincter and its ability to respond to signals, as well as the sensitivity and function of the rectum. Magnetic resonance imaging (MRI) is sometimes used to evaluate the sphincter. 

  • Anorectal ultrasonography evaluates the structure of the anal sphincters. 

  • Proctography, also known as defecography, shows how much stool the rectum can hold, how well the rectum holds it, and how well the rectum can evacuate it. 

  • Proctosigmoidoscopy allows doctors to look inside the rectum and lower colon for signs of disease or other problems that can cause fecal incontinence, such as inflammation, tumors, or scar tissue. 

  • Anal electromyography tests for nerve damage, which is often associated with injury during childbirth.

What are the Fetal 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:

  • Abdominal cramping

  • Abdominal pain

  • Bloating

  • Constipation

  • Diarrhea

  • Flatulence

  • The anus is irritated

  • The anus is itchy

  • Urinary incontinence

What are the Risk Factors of Fetal Incontinence?

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.

How is Fecal Incontinence Treated?

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.

  • Diet - Changes in the patient’s diet may help to control or eliminate fecal incontinence. Functional fecal incontinence is incontinence in the absence of any disease process. The problem may be caused by either diarrhea or constipation. Diarrhea may cause fecal incontinence when stools are too loose and the patient is unable to get to a bathroom in time. Control of diarrhea may be achieved with dietary changes, including eating diets that are high in fiber. Fiber can help by adding bulk to the stools and making them less watery. Conversely, if the problem is constipation, adding fiber to the diet will also help to avoid constipation. The patient should also increase fluid intake.

  • Medications - There are many medications that may be prescribed to help with fecal incontinence. If constipation is contributing to fecal incontinence, medications such as stool softeners and laxatives may be prescribed. It is important to note that patients should not take laxatives on a regular basis without consulting their physician, as frequent use of laxatives may lead to dependence on them to maintain bowel function.
    For diarrhea leading to fecal incontinence, physicians may prescribe different drugs to control diarrhea. Some drugs act by slowing bowel motility (the time it takes for stool to transit the bowel. Other drugs that may be used to treat fecal incontinence may include anti-diarrheal medications and medications that decrease the water content of the stool.

  • Bowel Training - Bowel training for fecal incontinence involves the patient going to the bathroom at prescribed times; for example, after a meal. This helps the patient establish predictability over when the toilet is needed. This technique may be helpful for patients who have fecal incontinence due to loss of anal sphincter control or loss of awareness of the need to have a bowel movement.

  • Surgical Repair - Surgery can be helpful in some cases, such as when anal muscles are damaged in childbirth or when the rectum protrudes through the anus (rectal prolapse). A sphincteroplasty is a procedure done by a colon and rectal surgeon to repair the sphincter. Mayo Clinic generally recommends this procedure only when done very shortly after the initial injury. Otherwise, incontinence tends to recur a year or two after the operation.
    Less common procedures may be considered for complex injuries, such as extensive nerve damage. Successful repair depends upon the severity of the injury, how long you have had the condition and whether an infection is present.

  • Nerve Stimulation - Nerve stimulation involves implanting a device that sends small electrical impulses continuously to the nerve (sacral or tibial) which controls defecation and voiding. While Mayo Clinic doctors perform nerve stimulation for urinary incontinence, studies have found the treatment to also be effective in some cases with fecal incontinence. 

What are the Various Surgical Procedures for Fecal Incontinence?

For some people surgery may present good option. Several different surgical procedures can be done, depending on the cause of incontinence.

  • Sphincteroplasty: Sphincteroplasty is a procedure used to repair defects of anal sphincter. It is a long-term solution and has the fewest complications.

  • Artificial bowel sphincter: If anal sphincter is damaged, an artificial sphincter can be used to replace it. The device is implanted around the anal canal. When inflated, it keeps the anal sphincter shut tight. External pump to deflate the device allows stool to be released.

  • Colostomy: Colostomy is a procedure where an opening is made from the colon (or large intestine) to the outside of the abdomen.
    The end of the shortened colon is brought to the surface of the abdomen to form the stoma, where the faeces will pass from the body. There is no sphincter in the stoma and there is no control over bowel movements. The person will need to continuously wear an ostomy appliance (a special bag) to contain the stool.

  • Sphincter repair / gracilis muscle transplant : Sphincter may be repaired by a technique of transferring a muscle from another part of the body and wrapping it around the anal canal to act like a sphincter. Sphincter repair is usually preformed on people who have an incompetent rectal sphincter as a result of injury or aging.

How to Prevent Fecal Incontinence?

To help reduce your chance of getting fecal incontinence, take the following steps:

  • Prevent constipation with a diet high in fiber and adequate fluids.

  • Pay attention to your diet and avoid foods that trigger diarrhea.

  • Try to maintain a regular bowel movement schedule.

  • Talk to your doctor if you are having trouble with diarrhea or constipation.

What if a child has Fecal Incontinence? 

A child with FI who is toilet trained should see a health care provider, who can determine the cause and recommend treatment. FI can occur in children because of a birth defect or disease, but in most cases it occurs because of constipation. 

Children often develop constipation as a result of stool withholding. They may withhold stool because they are stressed about toilet training, embarrassed to use a public bathroom, do not want to interrupt playtime, or are fearful of having a painful or unpleasant bowel movement.

Similarly to adults, constipation in children can cause large, hard stools that get stuck in the rectum. Watery stool builds up behind the hard stool and may unexpectedly leak out, soiling a child’s underwear. Parents often mistake this soiling as a sign of diarrhea.

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