Fecal Incontinence is the inability to control passage of liquid or solid stool from the rectum. Fecal incontinence affects 2 to 15 percent of adults in the United States. This condition affects men and women of all ages, but because people are embarrassed to talk about their symptoms, many people go untreated because they are unwilling to ask for help. There are effective treatments that can help, or even cure, the problem. However, fecal incontinence has long been a neglected subject, and for some fecal incontinence problems, we do not yet have completely effective treatments.
Types of fecal incontinence include:
• 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 that urine normally travels through).
• Rectovaginal Fistula: When a passage develops between the vagina and rectum, which results in stool being passed uncontrollably through the vagina.
- Basic Evaluation
- Other Possible Tests
- Treatment—Lifestyle Modifications
- Treatment—Medications and Surgery
- What Normally Allows You to Stay Continent?
- Causes of Fecal Incontinence
Women complain of the inability to control passage of gas from their rectum, or they complain of the inability to control their bowel movements (liquid or solid).
Fewer than half the women with fecal incontinence seek help from their doctors. Many people who suffer from incontinence have a high anxiety level and often have low self-esteem and self-hatred. The fear of losing stool can reduce the quality of life and often leads to isolation. Because of the private nature of the condition, people often do not share their feelings with others. This can lead to further anxiety and often depression. Unfortunately, this fear and anxiety can lead to upsetting the digestive system, causing further issues. Many treatments are available that can help reduce incontinence. Most people can get significant relief, and some can eliminate fecal incontinence all together. The best treatment for the negative emotions related to fecal incontinence is to seek medical treatment.
Your medical history and a thorough explanation of your symptoms to your doctor are very important.
What types of questions might I be asked at my first visit with the doctor?• When did your symptoms begin?
• Did your symptoms begin after a surgery such as a hysterectomy or surgery for your hemorrhoids?
• Do your symptoms relate to when you had children?
• How fast did your symptoms get worse?
• Do you feel the need to have a bowel movement, or does it just happen without your awareness?
• Do you feel like you completely empty your rectum after a bowel movement, or do you feel like your bowel movements are incomplete?
• Do you ever have to use your hand to help the bowel movement come out by either pressing on the inside or outside of the vagina?
• How are your symptoms affecting your quality of life?
• Are your symptoms affecting your ability to be intimate with your partner?
• Are you having any problems with low back pain or loss of sensation in your legs?
Your doctor will perform a pelvic exam that will look at how well your pelvic organs are supported. There also will be a careful digital examination of your rectum and anus to look for hemorrhoids and prior scarring. Your doctor will do an exam with her finger in your rectum to check the strength of your muscles and your ability to squeeze those muscles.
Other possible tests include:
This is an ultrasound, which is done with a probe placed into your rectum. The probe is about the size of a finger and should not be uncomfortable. The ultrasound allows your doctor to see the anal sphincter, which is the muscle that allows you to control your bowel movements. The sphincter may be weakened or torn, and this may be the reason you are having symptoms.
This radiology test allows your doctor to look carefully at the appearance of the muscles of the pelvic floor, which help you to control your bowel movements and also the nerves in your back, which are important to bowel control.
This test allows your doctor to see with an X-ray what is happening when you are having a bowel movement. It allows your doctor to see if there are blockages or pelvic organ prolapse. During this exam, barium paste is placed into your rectum and vagina. You will sit on a special toilet and you will be asked to bear down, as if you are having a bowel movement. While you are bearing down, X-ray images are taken that allows your doctor to see what happens to your pelvic muscles and bowels.
This test allows your doctor to see if the muscles of the rectum are strong and able to function properly. During this exam, a small air-filled balloon is inserted into your rectum. The balloon allows your doctor to determine if the muscles react properly to different pressures.
The Pelvic Control Center offers a range of services from initial diagnostic evaluation, to recommendations for treatment, to coordination of appropriate medical, behavioral, or surgical therapy. So that patients understand the medical issues and possible treatment options, The Pelvic Control Center staff makes sure that patients have access to educational materials and experienced professionals.
Strengthening/Retraining Pelvis and Sphincter Muscles
As part of your evaluation, your doctor might find that your pelvic and anal sphincter muscles are weakened, and recommend a course of physical therapy. A physical therapist will carefully evaluate the muscles of your back, abdomen and pelvis. They will teach you how to do pelvic floor muscle contractions correctly. These contractions, known as Kegel exercises, are designed to strengthen the pelvic floor muscles. These muscles support the bladder and bowel openings in both men and women. Strengthening the muscles of the pelvic floor can aid in preventing leakage of urine or feces with coughing, sneezing, lifting and other stressful movements.
Other benefits of Kegels include:
• Enhanced sexual function
• Conditioned muscles to make childbirth easier
• Decreased and/or prevented prolapse of pelvic organs
• Improved ability to pass stool
A course of biofeedback therapy might be recommended by the therapist. With biofeedback, a computer or machine shows you how your muscles are working, how well you can coordinate the use of these muscles with a full bowel, and teaches you how to improve your control. Sometimes the anal sphincter muscles do not relax properly when you empty the bowel, and so the rectum is not emptied completely. Biofeedback can help to teach you to use the correct muscles to empty the bowel effectively. Improvement of your symptoms will occur over a period of a few weeks to months.
If the sphincter muscles and nerves are not too severely damaged, biofeedback usually benefits 50 to 75 percent of the people who try it. This is not a "quick fix," and you will need to work hard at the exercises to make them effective.
In addition, sometimes the therapist will recommend electrical stimulation to further help in making your muscles stronger as part of your treatment plan. You can either purchase or rent one of these devices to use at home.
• Loperamide (Imodium®) helps in thickening stool consistency and decreases the number of bowel movements per day.
• Diphenoxylate (Lomotil®) also is used to thicken stool consistency and decrease bowel movements.
• Increased fiber intake is used to increase the size of the stool to decrease loss of liquid and very soft stool (examples: Metamucil and Benfiber). All are over-the-counter medications.
Anal sphincteroplasty is a procedure that can be done if the doctor thinks that your involuntary loss of stool is caused by an injured/separated sphincter muscle. An opening in the skin is made between the vagina and anus. The separated muscles are found and put back together with stitches, and the skin over the muscles also is sewn back together. About one-third of patients experience a separation of skin edges that typically heals spontaneously over time. Some patients also may have some difficulty with bowel movements after surgery.
Rectovaginal fistula repair
Rectovaginal fistula repair is a procedure in which the tract that connects the vagina and rectum separates, and the area between these two openings is closed in multiple tissue layers. An incision is made either between the vagina and anus or just inside the vagina. The tract is located, the tissues are separated and the area is closed with multiple tissue layers. In one-third of patients, the skin edges of the repair will separate. This separation will heal spontaneously over time.
A seton is a ribbon of material that is placed in a fistula to aid in healing. Thread, wire, rubber or medicated suture can be used as a seton. A seton can sometimes be placed by a physician in the clinic. On other occasions, it may be placed in an operating room, in combination with an examination under anesthesia. A seton works by draining the fistula tract in order to prevent bacteria from collecting (for example, in an abscess) and eroding more deeply into the patient's tissues. With drainage, the infection will pass, allowing operation at the site of origin. Previously, setons also were used to cut the fistula tract and/or induce scarring. None will experience significant discharge. All setons that are inserted are sutured, or stitched, to the tissue or otherwise secured. You should not worry about the seton moving up into your body.
What normally allows you to stay continent of stool?
The rectum is the lowest part of the large intestine that ends just before the anus. Stool can be stored here until it is ready to be eliminated. The anus is the opening of the lower intestine where solid waste is eliminated. Just on the inside of the anus are two rings of muscle around the anus or exit from the bowel. These two rings of muscle form the anal sphincter and are designed to hold in the bowel contents at all times except when you are sitting on the toilet and trying to empty the bowel.
• The external anal sphincter is the muscle that you use to hold on when the rectum is full and you feel that you
need to empty the bowel.
• The internal anal sphincter is an internal muscle responsible for keeping the anal canal closed at all times
except when there is an urge to empty the bowel. You do not have to think about keeping this muscle closed; it
When stool enters the rectum, the internal anal sphincter muscle automatically relaxes and opens up the top of the anal canal. This is normal and allows stool to enter the upper anal canal to be "sampled" by the very sensitive nerve cells in the upper anal canal. People with normal sensation can easily tell the difference between wind (gas, also called flatus), which can safely be passed if it is socially convenient without fear of soiling, diarrhea (very loose or runny stools needing urgent attention and access to a toilet) and a normal stool. Most people just know what is in the rectum without having to think about it.
If a normal stool is sensed and it is not convenient to find a toilet at that moment, bowel emptying is delayed by squeezing the external anal sphincter. Squeezing the external sphincter ensures that the stool is not simply expelled as soon as it enters the rectum, and in fact the stool is pushed back up out of the anal canal. For most people this is not a deliberate action - you should not need to think, "I must squeeze my anal sphincter muscles so that I do not have a bowel accident" — but this is actually what you do, subconsciously, without thinking about it.
This external sphincter squeeze does not need to last all the time until the toilet is found. Stool is propelled back into the rectum, and the rectum relaxes, and so the urge to empty the bowel is resisted and wears off. For most people, an urge to empty the bowel is felt, but if the time and place are not right, it is possible to delay bowel emptying, and the feeling of needing "to go" wears off very soon. Most people can then forget about the bowel for a while, and some can put off bowel emptying almost indefinitely, but may get reminders that the bowel is full at intervals until it is emptied. Continually resisting the urge to empty the bowel or ignoring the "call to stool" can lead to constipation, as the longer the stools stay in the colon and rectum, the more fluid is absorbed and the harder the stools become.
For this mechanism to work properly, you need several things:
• The internal and external anal sphincters need to be undamaged and working properly
• The stools should not be too soft or loose so that the sphincters can cope with holding on, but not so hard that they are difficult to pass.
• And you need the physical ability to get to and onto a toilet and to hold on until the correct place is reached.
As you can imagine, this is a delicate system and, unfortunately, there are many things that can go wrong.
Different causes of fecal incontinence and rectovaginal fistula
During a very difficult vaginal delivery or during a delivery that requires use of forceps, vacuum or episiotomy to help deliver your baby, a partial tear in the muscles of the anal sphincter can happen. If this tear doesn't heal properly, it can cause incontinence. This is called a chronic third- or fourth-degree laceration.
If a large tear occurs during a very difficult vaginal delivery and that tear does not heal properly, a connection can form between the vagina and the rectum. This is called a rectovaginal fistula and causes incontinence because stool can pass inadvertently from the rectum into the vagina. Birth trauma is the most common cause of fecal Incontinence in young women.
Aging has the greatest impact on bowel control in women over the age of 40.
Certain surgeries place you at risk for developing fecal incontinence. Most of these surgeries involve manipulation of the muscles in the pelvis or the sphincter itself. They include the following:
• Low Anterior Resection
Chronic diarrhea can cause fecal incontinence. Often, your doctor may try to control your diarrhea first to see if this helps in your bowel control. Inflammatory bowel disease is a disease can cause alternating constipation and diarrhea. Often, if your diarrhea can be controlled with medication or dietary changes, bowel control can improve.
This is a temporary condition that may be caused by a virus or bacteria. Your doctor may ask you for a stool sample to check if there is a "bug" causing your diarrhea. If an infection is confirmed, treatment with antibiotics may improve your bowel control.
Various medical conditions may cause fecal Incontinence. Some diseases affect the nerves in the pelvis that help you control your bowel movements; if these nerves are damaged, fecal incontinence occurs. The diseases that can cause nerve damage include:
• Diabetic neuropathy
• Multiple sclerosis
• Parkinson's disease
• Spinal cord injury
Congenital Anorectal Malformation
Some people are born with birth defects that can cause fecal incontinence.