Bowel Incontinence (Fecal Incontinence)

Fecal incontinence occurs because of an underlying disease or illness (it is not considered a "disease"). There are numerous potential causes and many patients have more than one reason to cause loss of bowel control.

• Damage to muscles and nerves may occur directly at the time of vaginal childbirth or after anal or rectal surgery.
• Neurologic diseases such as stroke, multiple sclerosis, spinal cord injury, and spina bifida can be potential causes of fecal incontinence.
• Complications of diabetes can also cause peripheral nerve damage leading to incontinence.
• Patients with inflammatory bowel disease (Crohn's disease, ulcerative colitis) and irritable bowel disease may develop fecal incontinence.
• Stool seepage is different than fecal incontinence.
• Minor staining can occur in people who have hemorrhoids, rectal fistula, rectal prolapse and poor hygiene.
• Other causes include chronic diarrhea, parasite infections, and laxative abuse.
• Paradoxical diarrhea or overflow incontinence may occur is a a person who has chronic constipation. In paradoxical diarrhea, stool fills the rectum, hardens and becomes impacted. Liquid stool leaks around the fecal mass, imitating incontinence.

Bowel incontinence refers to the inability to control the passage of small amount of stool, liquid or solid, or control flatus.

People are sometimes reluctant to discuss their lack of bowel control because of the social stigma attached to it. Their initial complaint might be

• anal itching (pruritis ani),
• a buttock skin infection, or
• breakdown of the skin and ulcers.

Taking a history is very important and the health care professional will spend time learning about how often loss of bowel control occurs, in what situations and whether it is solid, liquid, or gas. Past medical and surgical history is important, especially obstetric history or surgery of the anus, including hemorrhoids. It could be several years before the complication of a surgery or childbirth lead to fecal incontinence. Dietary habits and medications (including over-the-counter medications and laxative) will also be considered and evaluated.

Physical examination will likely include a rectal examination to assess sphincter tone. In females, a pelvic exam will also be performed.

While blood tests are not usually needed to make the diagnosis, other tests may be helpful in deciding the potential cause of fecal incontinence. Anal manometry measures the pressure within the rectum, both at rest and when the patient squeezes the anal sphincter. Nerve and muscle conduction studies may be considered. Ultrasound can evaluate the anal sphincters and look for muscle damage.

The treatment approach for a patient with fecal incontinence is individualized based upon the underlying cause. The purpose is to regulate bowel movements, decrease their frequency, and increase stool firmness and consistency. Nonsurgical and surgincal treatments are often recommended for bowel incontinence, these include:

• Diet
  • Eat 20 to 30 grams of fiber per day. This can make stool more bulky and easier to control.
  • Avoid caffeine. This may help prevent diarrhea.
  • Drink several glasses of water each day. This can prevent constipation.
• Medications such as Imodium, Lomotil, or Hyoscyamine should help make liquid stool more solid and easier to control.
• Increasing the strength of the muscles of the pelvic floor might be helpful. Kegel exercises and electrical stimulation may be recommended.
• Biofeedback is often used to help retrain the anal sphincters and have the patient appreciate the sensation of rectal fullness that comes just before the need to defecate.
• If the incontinence persists even after maximum medical therapy has been attempted, surgery may be an alternative.
• If damaged, attempts can be made to repair the muscles of the pelvic floor including the external anal sphincter.
• The internal anal sphincter function may be enhanced by injecting materials like silicone, carbon beads, or collagen.
• As a last resort, where all other options have failed, a colostomy may be performed, where the colon is diverted through the abdominal wall to empty into a removable bag.

In children, fecal incontinence (also called encopresis) is often due to chronic constipation and overflow incontinence or diarrhea. By definition, there should be at least one inappropriate bowel movement per month for at least three months in a child older than age 4 years. The incontinence usually happens during the day and not at night.

• Most often, the diagnosis is made by history and physical examination by the health care professional and further testing is not needed.
• Treatment is directed at developing a more routine bowel evacuation schedule and may require changes in diet, behavior modification, and the addition of stool bulking agents.

Maintaining sphincter tone may prevent fecal incontinence. This might include preventing constipation by increasing fiber in the diet and keeping well hydrated and avoiding straining to promote a bowel movement.

Unfortunately, many times the cause of incontinence is childbirth anal surgery. It may be years until the symptoms of incontinence arise.

The frequency of fecal incontinence increases with age. Once it occurs, the patient may be able to control the symptoms with diet, medication, and exercise. Many patients may initially benefit from surgery, but that benefit gradually decreases over the years and incontinence may recur.