What you need to know about bowel incontinence

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Treatments for bowel incontinence aim to help restore bowel control or reduce its severity.

Options include medications, dietary changes, bowel training, stool impaction therapy. If these do not work, surgery may be recommended.

If an underlying condition is detected, this will need appropriate treatment.

Medications

These include:

• anti-diarrheal medications, such as loperamide, or Imodium
• laxatives, such as milk of magnesia, may be used in the short term, if the problem stems from chronic constipation
• medications that decrease bowel motility, or decrease water content in the stool

Dietary changes

A change of diet can sometimes relieve bowel incontinence. A food diary can help monitor the impact of different foods.

Drinking more fluid and eating more fiber-rich food can help reduce bowel incontinence due to constipation. High-fiber foods that add bulk to the stools may also help people with chronic diarrhea.

Bowel training

Patients with poor sphincter control or low awareness of the urge to defecate may find a bowel training program effective.

This can involve:

• exercises to help restore the strength of vital muscles for bowel control
• learning to use the bathroom at certain times of the day, such as after a meal

Pelvic floor muscle training, or Kegel exercises, can help strengthen muscles that have been weakened or stretched during labor. Women are advised to do the exercises several times a day during pregnancy and for about 2 months after childbirth.

Biofeedback

This is another type of bowel training.

A pressure-sensitive probe is inserted into the anus. Each time the muscles of the anal sphincter contract around the probe, the device senses it. This can give the patient an idea of the patterns of their muscle activity.

By practicing muscle contractions and viewing their strength and response on a screen, the patient can learn to strengthen those muscles.

Other intervention

Stool impaction treatment may be needed to remove an impacted stool, if other treatment is not effective. The surgeon uses two gloved fingers to break the stool into small pieces, making it easier to expel.

If the problem is caused by fecal impaction, and other treatments are ineffective, an enema may help. A small tube is placed into the anus, and a special solution is inserted to wash out the rectum.

In sacral nerve stimulation, four to six small needles are inserted into the muscles of the lower bowel. The muscles are stimulated by an external pulse generator that emits electrical pulses.

Patients who respond well to this treatment may have permanent pulse generator, similar to a pacemaker, implanted under the skin of the buttock. The sacral nerve runs from the spinal cord to muscles in the pelvis and is involved in bowel and urinary continence.

Surgery

Surgery is normally only used if other treatments have not worked or to treat an underlying condition.

Sphincteroplasty is surgery to repair a damaged or weakened anal sphincter. The surgeon removes damaged muscle, overlaps the muscle edges and sews them back together. This provides extra support to the muscles and tightens the sphincter.

Stimulated graciloplasty, or gracilis muscle transplant, uses a small amount of muscle from the patient’s thigh to create an artificial sphincter. Electrodes attached to a pulse generator are inserted into the artificial sphincter, and impulses gradually change the way the muscles work.

Sphincter replacement uses an inflatable cuff to replace damaged anal sphincter. The cuff is implanted around the anal canal. When inflated, the cuff 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 10 minutes later.

Surgery for a prolapsed rectum may be done if other treatments have not worked. The sphincter muscle may be repaired at the same time.

A rectocele may be corrected by surgery, if it leads to significant symptoms of fecal incontinence.

Prolapsed internal hemorrhoids may prevent the anal sphincter from closing properly, resulting in bowel incontinence. Hemorrhoidectomy is a surgical procedure to remove them.

A colostomy can be used as a last resort. The 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.

Accidental fecal leakage normally only affects adults when they have severe diarrhea.

Chronic fecal incontinence can involve frequent or occasional accidental leakage, an inability to hold in gas, silent leakage of feces during daily activities or exertion, or not reaching the bathroom in time.

Two types of bowel incontinence are:

• urge bowel incontinence, when the person has a sudden urge to use the bathroom but is unable to get there in time
• passive soiling, where nothing indicates that a bowel movement is about to occur

The type of stools passed during bowel incontinence can vary:

• the person breaks wind and passes a small piece of stool
• stools may be liquid
• stools are solid

Episodes may occur daily, weekly, or monthly.

Other signs and symptoms may include:

• abdominal pain or cramping
• bloating, flatulence or both
• constipation or diarrhea
• the anus is irritated or itchy
• urinary incontinence

Fecal incontinence can be a relatively small problem, resulting in the occasional soiling of underwear, or it can be devastating, with a total lack of bowel control.

People are more likely to have fecal bowel incontinence if they have:

• nerve damage, due, for example, to multiple sclerosis, long-term diabetes, or other conditions that affect the nerves that control defecation
• Alzheimer’s disease, because this involves dementia and nerve damage
• physical disability, as this can make it harder to reach the bathroom or to undress in time

Women are more likely to experience it, possibly as a complication of childbirth.

Why does it happen?

After digesting food, the digestive system moves waste, or feces toward the rectum, the tube that links the intestines to the anus. The rectum stores the waste until the body is ready to expel it.

As the rectum fills up, the rectal walls expand. Stretch receptors, or nerves, in the rectal walls stimulate the desire to defecate. If the person does not defecate on feeling this urge, the stools may return to the colon, where more water is absorbed.

When the rectum is full, the increased pressure forces the walls of the anal canal apart, and peristaltic waves push the feces into the canal.

As stools enter the anal canal, the rectum shortens. Internal and external sphincters allow the stools to be passed by causing muscles to pull the anus up over the exiting feces.

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

Bowel incontinence can happen for a number of reasons:

The sphincter muscles do not work as they should. Childbirth can cause the sphincter muscles to become stretched and torn, especially if forceps or other devices are used during delivery, or if the mother had an episiotomy. A complication of bowel or rectal surgery and some other types of injury can also cause damage to the sphincter muscles.

Diarrhea can make it difficult for the rectum to hold the stools. Recurring diarrhea, due, for example, to Crohn’s disease, irritable bowel syndrome (IBS), or ulcerative colitis, can lead to scarring in the rectum and bowel incontinence.

Constipation can lead to bowel incontinence. If solid stool becomes impacted, it may be too hard to come out. The muscles of the rectum can stretch and weaken, and watery stools may then leak around the impacted stool and seep out of the anus. This is called overflow of the bowel.

Other causes include:

• tumors in the rectum, as in rectal cancer
• rectal prolapse, when the rectum drops down into the anus
• rectocele, when the rectum protrudes through the vagina
• hemorrhoids, which can result in incomplete closure of the anal sphincter
• chronic laxative abuse

Certain foods can foods cause diarrhea and worsen the symptoms of fecal incontinence in some people. Examples include spicy, fatty, or greasy foods, cured or smoked meats, and dairy products for those with a lactose intolerance.

Drinks containing caffeine or artificial sweeteners may act as laxatives.

A physician will ask about symptoms, bowel habits, diet, medical history, lifestyle, and so on. The individual should explain openly, honestly and comprehensively, to find the best treatment.

The doctor may examine the patient’s anus and surrounding area for any damage, hemorrhoids, infections, and other conditions. They may use a pin or probe to examine this area of skin and check for nerve damage.

A digital rectal examination (DRE) may be necessary, in which the surgeon inserts a sterile gloved finger into the anus and up into the rectum.

This can identify:

• constipation
• tumors
• muscle problems
• a rectal prolapse

Further tests may require the help of a gastroenterologist, a doctor specialized in conditions and diseases of the digestive system or a proctologist, who specializes in conditions and diseases of the rectum and the anus.

Endoscopy involves inserting an endoscope, a long, thin flexible tube with a light source and video camera at the end, through the anus into the rectum. Images on a screen may reveal any obstruction, damage, or inflammation in the rectum.

In anal manometry, the doctor inserts a narrow, flexible tube into the patient’s rectum via the anus. A balloon at the tip is then expanded. This can assess how tight the anal sphincter is, how sensitivity the nerves are, and how well the muscles are functioning.

An anorectal ultrasound scan can evaluate the structure of the sphincter. A narrow, wand-like device is inserted into the anus and rectum. It produces video images of internal structures by emitting sound waves that bounce off the walls of the rectum and anus.

Defecography, or protography, involves taking x-ray images with barium liquid. The patient will be asked to pass a stool while the x-rays are taken. This can determine how much stool the rectum can hold, and how well the stools are evacuated.

In anal electromyography, tiny needle electrodes are inserted into the muscle around the anus. A light electrical current is sent through the electrodes, and signals show up as images on a screen. This can reveal any damage to the nerves between from the rectum to the brain, and it may show where the damage is.

To prevent bowel incontinence, or reduce the severity of symptoms people are advised to:

• avoid constipation, for example, by getting more exercise, eating foods that are high in fiber, and consuming plenty of liquids
• seek treatment for diarrhea, for example, by addressing an infection in the digestive system
• avoid straining when defecating, as this can weaken the anal sphincter muscles

While waiting to find a successful treatment, a range of discreet products and pads are available to help people cope with incontinence without embarrassment.