Fecal incontinence

Fecal incontinence
Specialty	Gastroenterology

Fecal incontinence is the loss of regular control of the bowels. Involuntary excretion and leaking are common occurrences for those affected. Subjects relating to defecation are often socially unacceptable, thus those affected are often beset by feelings of shame and humiliation. Some refuse to seek medical help, and instead attempt to self-manage the problem. This can lead to social withdrawal and isolation, which can turn into cases of agoraphobia. Such effects may be reduced by undergoing prescribed treatment, taking prescribed medicine and making dietery changes.

Prevalence

Fecal incontinence affects people of all ages. Fecal incontinence is more common in women than in men, and more in older adults than in younger adults. It is not, however, a normal part of aging.

Causes

Fecal incontinence can have several causes:

• diarrhea
• pelvic floor dysfunction
• fecal impaction
• severe muscular strain in the abdominal area, particularly when giving birth
• episiotomy complications
• damage to the muscles or nerves of the anal sphincters
• damage to the muscles or nerves of the rectum
• loss of storage capacity in the rectum, e.g. due to surgery
• Spinal cord injury
• Various medications, particularly stimulants.

or a combination thereof.

Muscle damage

Fecal incontinence is most often caused by injury to one or both of the ring-like muscles at the end of the rectum called the internal and external anal sphincters. During normal function, these sphincters help retain stool. When damaged, the operation of the muscles is compromised, and leaks may occur. In women, the damage often happens during childbirth. The risk of injury is greatest when the birth attendant uses forceps to help the delivery or does an episiotomy. Hemorrhoid surgery can damage the sphincters as well. A pelvic tumor that grows in or becomes attached to the rectum or anus also can cause muscle damage, as can surgery to remove the tumor.

Nerve damage

Fecal incontinence can also be caused by damage to the nerves that control the anal sphincters or to the nerves that detect stool in the rectum. Damage to the nerves controlling the sphincter muscles will render the muscles unable to work effectively and incontinence may occur. If the sensory nerves are damaged, detection of stool in the rectum is disabled, and one will not feel the need to defecate until too late. Nerve damage can be caused by childbirth, long-term constipation, stroke, and diseases that cause nerve degeneration, such as diabetes and multiple sclerosis.

Loss of storage capacity

Normally, the rectum stretches to hold stool until it is voluntarily released. But rectal surgery, radiation treatment, and inflammatory bowel disease can cause scarring, which may result in the walls of the rectum becoming stiff and less elastic. The rectum walls are unable to stretch as much and are unable to accommodate as much stool, resulting in fecal incontinence. Inflammatory bowel disease also can make rectal walls very irritated and thereby unable to contain stool.

Diarrhea

Main article: Diarrhea

Diarrhea, or loose stool, is more difficult to control than solid stool that is formed. For people who are normally unaffected by fecal incontinence, this can manifest itself as a temporary form.

Pelvic floor dysfunction

Main article: Pelvic floor

Abnormalities of the pelvic floor can lead to fecal incontinence. Examples of some abnormalities are decreased perception of rectal sensation, decreased anal canal pressures, decreased squeeze pressure of the anal canal, impaired anal sensation, a dropping down of the rectum (rectal prolapse), protrusion of the rectum through the vagina (rectocele), and generalized weakness and sagging of the pelvic floor. Often the cause of pelvic floor dysfunction is childbirth, and incontinence does not show up until the midforties or later.

Diagnosis

The doctor will ask health-related questions and do a physical exam and possibly other medical 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.
• 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 the stool.
• Proctosigmoidoscopy allows doctors to look inside the rectum for signs of disease or other problems that could cause fecal incontinence, such as inflammation, tumors, or scar tissue.
• Anal electromyography tests for nerve damage, which is often associated with obstetric injury.

Treatment

Treatment depends on the cause and severity of fecal incontinence; it may include dietary changes, medication, bowel training, or surgery. More than one treatment may be necessary as some forms of fecal incontinence can be rather complicated. Most physicians that specialize in gastroenterology, rehabilitative medicine, neurotrauma, and pediatric surgery have expierence with bowel management programs. "Social continence" may be achievable for some people using a bowel management program that cleans out the colon daily.

There are several devices and medications available to combat fecal incontinence. One method of relatively easy treatment is the use of diapers. Both cloth and disposable diapers are available for fecal incontinence. Pull-up type diapers are not recommended for fecal incontinence. Thicker-type diapers such as the Secure X-Plus, Molicare, or Abena X-Plus are generally seen as the best method of treating fecal incontinece, as these diapers are thicker and have inner linings to help control fecal matter better.

Dietary changes

Food affects the consistency of stool and how quickly it passes through the digestive system. One way to help control fecal incontinence in some persons is to eat foods that add bulk to stool, decreasing the water content of the feces and making it firmer. Also, avoid foods and/or drinks that contribute to the problem. They include foods and drinks containing caffeine, like coffee, tea, and chocolate, which relax the internal anal sphincter muscle. Another approach is to eat foods low in fiber to decrease the work of the anal sphincters. Fruit can act as a natural laxative and should be eaten sparingly.

Individuals affected with fecal incontinence can make dietary adjustments to assist in management of the condition.

• A good approach is a food diary. Such a diary can document what is being eaten, how much has been eaten, and records each incontinent episode. After a few days, a pattern between certain foods and incontinence could be detected. After problem foods are identified cutting back on them could lead to an improvement in the incontinence. Foods that typically cause diarrhea, and so should probably be avoided, include
  • caffeine
  • cured or smoked meat like sausage, ham, or turkey
  • spicy foods
  • alcohol
  • dairy products like milk, cheese, and ice cream
  • fruits like apples, peaches, or pears
  • fatty and greasy foods
  • sweeteners, such as sorbitol, xylitol, mannitol, aspartame and fructose, which are found in diet drinks, sugarless gum and candy, chocolate, and fruit juices

Medication

Medication consists primarily of antipropulsive drugs.

Surgery

Surgical procedures used to treat otherwise intractable fecal incontinence include:

• Colostomy

• Stimulated graciloplasty creates a new anal sphincter, using gracilis muscle from the thigh and a temporary electric device to retrain the muscle for its new function.

• Artificial anal sphincter (also known as artificial bowel sphincter and neosphincter). The usual surgical approach is through the perineum but because in many cases of fecal incontinence the perineum is damaged, for women an alternative approach is through the vagina.

• Temperature-controlled radiofrequency energy (SECCA).

• Antegrade continent enema stoma. This procedure is often necessary in addition to others, when fecal incontinence is complicated by neuropathy and/or an incomplete internal anal sphincter.

• Sacral nerve stimulation, the newest of these surgical procedures, involves implanting an electric device that causes contraction of the anal sphincter. To defecate, the person holds a small magnet against the skin over the device, temporarily turning off the device and allowing the sphincter to relax. This procedure requires an intact anal sphincter.

Graciloplasty and artificial anal sphincter both significantly improve continence, with artificial anal sphincter being superior, however both methods have high rates of complications.

Sacral Neuromodulation (SNM)

Recently, electrical stimulation of sacral nerves has been used to treat fecal incontinence, mainly of neurogenic origin, in order to obtain a “modulation” effect on neural activities, by supplying additional electrical stimulation to both pelvic floor muscles, and sensitive neurological pathways. This therapeutic approach is referred to as Sacral Neuromodulation (SNM).

See: Sacral Neuromodulation in fecal incontinence. Full Journal article.

See also

• Anal leakage
• Encopresis
• Soiling

External links

• [1]
• General Information on Bowel Incontinence
• [2]
• NICE guidance IPG159: Stimulated graciloplasty for faecal incontinence
• NICE guidance IPG099: Sacral nerve stimulation for faecal incontinence