Bowel Incontinence or Fecal Incontinence – Causes and Prevention.

What is Bowel Incontinence?

Bowel Incontinence – also called fecal incontinence – is the term used when bowel movements cannot be controlled. Stool (feces/waste/poop) leaks out of the rectum when you don’t want it too, which means not during planned bathroom breaks. This leakage occurs with or without your knowledge. Fecal incontinence happens more often in women than in men and also happens more often among older people.

The term bowel incontinence is used if any of these situations occur:

• Stool leaks out when passing gas.
• Stool leaks out due to physical activity/daily life exertions.
• Feeling like you have to go and not being able to make it to the bathroom in time.
• Stool is seen in the underwear after a normal bowel movement.
• There is complete loss of bowel control.

Pathophysiology

Fecal continence is maintained by the structural and functional integrity of the anorectal unit. Normal anal sphincter function is a critical part of continence. The anal sphincter is comprised of 2 components: the internal anal sphincter (IAS), which is a 0.3-0.5 cm expansion of the circular smooth muscle layer of the rectum and the external anal sphincter (EAS), a 0.6-1.0 cm expansion of the levator ani muscles. The IAS is chiefly responsible for maintaining continence at rest and contributes approximately 70-80% of the resting sphincter tone. This barrier is reinforced during voluntary squeeze by the EAS, the anal mucosal folds, and the anal endovascular cushions.

These barriers are further augmented by the puborectalis muscle, which forms a sling around the rectum and creates a forward pull to reinforce the anorectal angle. The anorectal angle, which is approximately 90 degrees at rest, is created as the rectum perforates the levator complex. During voluntary squeeze, the angle becomes more acute, whereas during defecation, the angle becomes more obtuse. Innervation of the EAS is from the pudendal nerve, a mixed motor and sensory nerve that arises from the second, third, and fourth sacral nerves (S2, S3, and S4). Innervation of the puborectalis arises more directly from the sacral nerves listed above.

When defecation is desired, the anorectal angle straightens (which is facilitated by squatting or sitting), and abdominal pressure is increased by straining. This results in descent of the pelvic floor, contraction of the rectum, inhibition of the external anal sphincter, and subsequent evacuation of the rectal contents.

If evacuation of the rectum is not socially appropriate, sympathetically mediated inhibition of the smooth muscle of the rectum and voluntary contraction of EAS and puborectalis musculature occur. The anorectal angle becomes more acute and prevents the bolus of stool from descending further. The contents of the rectum are forced back into the compliant rectal reservoir above the levators, which allows the IAS to recover and contract again. A decrease in the compliance of this rectal reservoir has been associated with fecal urgency and anal incontinence. The exact mechanism of this is unclear and debate continues as to whether it is a cause or result of anal incontinence.

In essence, any process that interferes with these mechanisms, including trauma from vaginal delivery or a neurological insult, can result in fecal incontinence.

Causes of Bowel Incontinence

Reasons people have bowel incontinence include:

• Ongoing (chronic) constipation. This causes the anus muscles and intestines to stretch and weaken, leading to diarrhea and stool leakage.
• Fecal impaction. It is most often caused by chronic constipation. This leads to a lump of stool that partly blocks the large intestine.
• Long-term laxative use.
• Colectomy or bowel surgery.
• Not sensing that it’s time to have a bowel movement.
• Emotional problems.
• Gynecological, prostate, or rectal surgery.
• Injury to the anal muscles due to childbirth (in women).
• Nerve or muscle damage (from injury, tumor, or radiation).
• Severe diarrhea that causes leakage.
• Severe hemorrhoids or rectal prolapse.
• Stress of being in an unfamiliar environment.

Who is at risk for fecal incontinence?

Anyone can experience fecal incontinence, but certain people are more likely to get it than others. You may be at risk if:

• You’re over the age of 65
• You’re a woman
• You’re a woman who has given birth
• You have chronic constipation
• You have a disease or injury that caused nerve damage

Symptoms

Conditions that lead to fecal incontinence can also cause abdominal pain.

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.

What are possible complications of fecal incontinence?

Complications are problems caused by your condition. With fecal incontinence, complications may include:

• Emotional and social distress. Fecal incontinence is embarrassing. You may start to skip work and social situations. Some people become depressed because of this problem.
• Physical irritation. Frequent exposure to feces and wiping can irritate the skin around your anus.
• Poor nutrition. Over time, severe fecal incontinence may mean that your body isn’t getting enough nutrition from your food. Your healthcare provider may advise nutritional supplements.

Diagnosis of Bowel Incontinence

Discussing bowel incontinence can provide clues for a doctor to help make the diagnosis. During a physical examination, a doctor may check the strength of the anal sphincter muscle using a gloved finger inserted into the rectum.

Other tests may be helpful in identifying the cause of bowel incontinence, such as:

Stool testing. If diarrhea is present, stool testing may identify an infection or other cause.

Endoscopy. A tube with a camera on its tip is inserted into the anus. This identifies any potential problems in the anal canal or colon. A short, rigid tube (anoscopy) or a longer, flexible tube (sigmoidoscopy or colonoscopy) may be used.

Anorectal manometry. A pressure monitor is inserted into the anus and rectum. This allows measurement of the strength of the sphincter muscles.

Endosonography. An ultrasound probe is inserted into the anus. This produces images that can help identify problems in the anal and rectal walls.

Nerve tests. These tests measure the responsiveness of the nerves controlling the sphincter muscles. They can detect nerve damage that can cause bowel incontinence.

MRI defecography. Magnetic resonance imaging of the pelvis can be performed, potentially while a person moves their bowels on a special commode. This can provide information about the muscles and supporting structures in the anus, rectum, and pelvis.

Balloon expulsion test. This is where your health care provider inserts a small balloon filled with water into your rectum. You’ll then go to the bathroom and push out the balloon. If it takes longer than 3 minutes, you may have trouble passing stools.

Colonoscopy. Your health care provider will insert a flexible tube into your rectum to closely examine your colon.

Treatment of Bowel Incontinence

Your doctor will need to evaluate your symptoms and advise whether you need to be screened for colorectal cancer before you begin any home remedies. In addition, he or she can recommend the home remedies that are most effective for your specific condition.

While there are supplements for everything these days, Dr. Marines recommends starting with a few tried-and-true home remedies to relieve symptoms of bowel incontinence:

• Eating plenty of fiber. Did you know that most people don’t get the daily recommended amount of fiber, which is 38 grams for men and 25 grams for women? Fiber helps bulk up your stool, making it less likely to accidentally leak loose stool.
• Limiting caffeine. Caffeine increases the rate at which your intestinal muscles push stool through your colon. With less time for your stool to absorb water and bulk up, you’re more likely to accidentally leak loose stool.
• Keeping a food journal and avoiding problem foods. By tracking both what you eat and your bowel movements, you may find that certain foods make your bowel movements looser. Make an effort to avoid these foods, especially if you can’t be near a restroom.
• Having a bowel regimen. Try to plan your bowel movements for the same time every day, if possible. If your bowel incontinence is more frequent, plan to use the restroom before leaving your house.
• Performing Kegel exercises. This exercise can help strengthen the pelvic floor muscles that support your bowel, helping to keep stool from leaking out. Try using post-it notes or phone alerts to remind yourself to do these several times a day.
• The occasional water enema. This more invasive at-home option can help provide more predictable bowel movements. While this may be okay to try initially, approach with caution and consult your doctor if you need to do this frequently.

The key thing to know about these home remedies is that they’re not a substitute for speaking with your doctor — these are just the things you can try before it’s time to consider more time-consuming or advanced treatment options.

Medications

Depending on the cause of fecal incontinence, options include:

• Anti-diarrheal drugs such as loperamide hydrochloride (Imodium A-D) and diphenoxylate and atropine sulfate (Lomotil)
• Bulk laxatives such as methylcellulose (Citrucel) and psyllium (Metamucil), if chronic constipation is causing your incontinence

Exercise and other therapies

If muscle damage is causing fecal incontinence, your doctor may recommend a program of exercise and other therapies to restore muscle strength. These treatments can improve anal sphincter control and the awareness of the urge to defecate.

Options include:

• Kegel exercises. Kegel exercises strengthen the pelvic floor muscles, which support the bladder and bowel and, in women, the uterus, and may help reduce incontinence. To perform Kegel exercises, contract the muscles that you would normally use to stop the flow of urine.

Hold the contraction for three seconds, then relax for three seconds. Repeat this pattern 10 times. As your muscles strengthen, hold the contraction longer, gradually working your way up to three sets of 10 contractions every day.

• Biofeedback. Specially trained physical therapists teach simple exercises that can increase anal muscle strength. People learn how to strengthen pelvic floor muscles, sense when stool is ready to be released and contract the muscles if having a bowel movement at a certain time is inconvenient. Sometimes the training is done with the help of anal manometry and a rectal balloon.
• Bowel training. Your doctor may recommend making a conscious effort to have a bowel movement at a specific time of day: for example, after eating. Establishing when you need to use the toilet can help you gain greater control.
• Bulking agents. Injections of nonabsorbable bulking agents can thicken the walls of your anus. This helps prevent leakage.
• Sacral nerve stimulation (SNS). The sacral nerves run from your spinal cord to muscles in your pelvis, and regulate the sensation and strength of your rectal and anal sphincter muscles. Implanting a device that sends small electrical impulses continuously to the nerves can strengthen muscles in the bowel.

• Posterior tibial nerve stimulation (PTNS/TENS). This minimally invasive treatment stimulates the posterior tibial nerve at the ankle. In a large study, however, this therapy didn’t prove to be significantly better than a placebo.
• Vaginal balloon (Eclipse System). This is a pump-type device inserted in the vagina. The inflated balloon results in pressure on the rectal area, leading to a decrease in the number of episodes of fecal incontinence.
•  Radiofrequency therapy. Known as the Secca procedure, this involves delivering temperature-controlled radiofrequency energy to the wall of the anal canal to help improve muscle tone. Radiofrequency therapy is minimally invasive and is generally performed under local anesthesia and sedation. However, this procedure isn’t always covered by insurance.

Surgery

Treating fecal incontinence may require surgery to correct an underlying problem, such as rectal prolapse or sphincter damage caused by childbirth. The options include:

• Sphincteroplasty. This procedure repairs a damaged or weakened anal sphincter that occurred during childbirth. Doctors identify an injured area of muscle and free its edges from the surrounding tissue. They then bring the muscle edges back together and sew them in an overlapping fashion, strengthening the muscle and tightening the sphincter. Sphincteroplasty may be an option for patients trying to avoid colostomy.
• Treating rectal prolapse, a rectocele or hemorrhoids. Surgical correction of these problems will likely reduce or eliminate fecal incontinence. Over time, the prolapse of the rectum through the rectal sphincter damages the nerves and muscles of the sphincter. The longer the prolapse goes untreated, the higher will be the risk of fecal incontinence not resolving after surgery.
• Colostomy (bowel diversion). This surgery diverts stool through an opening in the abdomen. Doctors attach a special bag to this opening to collect the stool. Colostomy is generally considered only after other treatments haven’t been successful.

Dietary changes

You may be able to gain better control of your bowel movements by:

Keeping track of what you eat. What you eat and drink affects the consistency of your stools. Make a list of what you eat for a few days. You may discover a connection between certain foods and your bouts of incontinence. Once you’ve identified problem foods, 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, 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.

Getting adequate fiber. If constipation is causing fecal incontinence, your doctor may recommend eating fiber-rich foods. Fiber helps make stool soft and easier to control. If diarrhea is contributing to the problem, high-fiber foods can also add bulk to your stools and make them less watery.

Fiber is predominately present in fruits, vegetables, and whole-grain breads and cereals. Aim for 25 grams of fiber a day or more, 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

You can help avoid further discomfort from fecal incontinence 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. Showering or soaking in a bath also may help
• Soap can dry and irritate the skin. So can rubbing with dry toilet paper. Premoistened, alcohol-free, perfume-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. 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.

Prevention of Bowel Incontinence

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.