Faecal Incontinance

What is Faecal incontinence?

Faecal incontinence is the inability to control bowel movements, causing stool (faeces) to leak unexpectedly from the anus. Faecal incontinence ranges from an occasional leakage of stool while passing gas to a complete loss of bowel control.

What are the main types?

Urge incontinence: Inability to resist the urge to defecate, which comes on so suddenly that they don't make it to the toilet in time.

Passive incontinence: Leakage of stools in those who are not aware of the need to pass stool.

What can cause Faecal incontinence?

Muscle damage

Injury to the rings of muscle at the end of the rectum (anal sphincter) may make it difficult to hold stool back properly. This can occur perineal tears that can happen during difficult child birth, episiotomy injury, post surgical (inappropriate or careless perianal surgery for fissures/ haemorrhoids etc) and trauma to the sphincter.

Nerve damage

Injury to the nerves that sense stool in the rectum or those that control the anal sphincter can lead to faecal incontinence. The nerve damage can be caused by childbirth, constant straining during bowel movements, spinal cord injury or stroke. Some diseases, such as diabetes and multiple sclerosis, also can affect these nerves and cause damage that leads to faecal incontinence.

Constipation

Chronic constipation may lead to a mass of dry, hard stool in the rectum (impacted stool) that is too large to pass. The muscles of the rectum and intestines stretch and eventually weaken, allowing watery stool from farther up the digestive tract to move around the impacted stool and leak out. Chronic constipation may also cause nerve damage that leads to faecal incontinence.

Diarrhoea

Solid stool is easier to retain in the rectum than is loose stool, so the loose stools of diarrhoea can cause or worsen faecal incontinence.

Loss of storage capacity in the rectum

Normally, the rectum stretches to accommodate stool. If your rectum is scarred or your rectal walls have stiffened from surgery, radiation treatment or inflammatory bowel disease, the rectum can't stretch as much as it needs to, and excess stool can leak out.

Rectal prolapse

Faecal incontinence can result if the rectum drops down into the anus.

Rectocele

In women, faecal incontinence can occur if the rectum protrudes through the vagina.

Dementia

Faecal incontinence is often present in late-stage Alzheimer's disease and dementia.

Physical disability

Being physically disabled may make it difficult to reach a toilet in time. An injury that caused a physical disability also may cause rectal nerve damage, leading to faecal incontinence. Also, inactivity can lead to constipation, resulting in faecal incontinence.

What complications can occur?

Emotional distress. The loss of dignity associated with losing control over one's bodily functions can lead to embarrassment, shame, frustration, anger and depression. It's common for people with faecal incontinence to try to hide the problem or to avoid social engagements.

Skin irritation. The skin around the anus is delicate and sensitive. Repeated contact with stool can lead to pain and itching, and potentially to sores (ulcers) that require medical treatment.

How is this diagnosed?

Clinical examination

Your surgeon will ask questions about your condition and perform a physical exam that usually includes a visual inspection of your anus. A probe may be used to examine this area for nerve damage. Normally, this touching causes your anal sphincter to contract and your anus to pucker.

Your doctor inserts a gloved and lubricated finger into your rectum to evaluate the strength of your sphincter muscles and to check for any abnormalities in the rectal area. During the exam your doctor may ask you to bear down, to check for rectal prolapse.

Special tests

Balloon expulsion test

A small balloon is inserted into the rectum and filled with water. You are then asked to go to the toilet and expel the balloon. The length of time it takes to expel the balloon is recorded. A time of one minute or longer is usually considered a sign of a defecation disorder.

Anal manometry

A narrow, flexible tube is inserted into the anus and rectum. A small balloon at the tip of the tube may be expanded. This test helps measure the tightness of your anal sphincter and the sensitivity and functioning of your rectum.

Anorectal ultrasonography

A narrow, wand-like instrument is inserted into the anus and rectum. The instrument produces video images that allow your doctor to evaluate the structure of your sphincter.

Proctography

X-ray video images are made while you have a bowel movement on a specially designed toilet. The test measures how much stool your rectum can hold and evaluates how well your body expels stool.

Proctosigmoidoscopy

A flexible tube is inserted into your rectum to inspect the last two feet of the colon (sigmoid) for signs of inflammation, tumors or scar tissue that may cause faecal incontinence.

Colonoscopy

A flexible tube is inserted into your rectum to inspect the entire colon.

Magnetic resonance imaging (MRI)

MRI can provide clear pictures of the sphincter to determine if the muscles are intact and can also provide images during defecation (defecography).

How is it treated?

If diarrhoea is contributory: Anti-diarrhoeal drugs such as loperamide hydrochloride (Imodium) and diphenoxylate and atropine sulfate (Lomotil). High-fiber foods can also add bulk to your stools and make them less watery.

If chronic constipation is causing your incontinence: Bulk laxatives such as methylcellulose and psyllium, drinking plenty of fluids and eating fiber-rich foods.

If muscle damage is causing faecal incontinence: your surgeon may recommend a program of exercise and other therapies to restore muscle strength.

Treatment Options

There are many treatment options available because each patient's cause for the incontinance is different and therefore need attention to varied problems. However the success rates of all these options can be varied between patients. Therefore sometimes one may need to try several options to achieve success.

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

Simple exercises that can increase anal muscle strength and will strengthen pelvic floor muscles. It will increase the senses 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 re-training

Your surgeon 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.

Sacral nerve stimulation (SNS)

The sacral nerves run from your spinal cord to muscles in your pelvis. These nerves 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. This treatment is usually done only after other treatments are tried.

Posterior tibial nerve stimulation (PTNS/TENS)

This minimally invasive treatment may be helpful for some people with faecal incontinence, but the results can be varied.

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 faecal incontinence. Results for women have been promising, but more data are needed.

Sphincteroplasty

This procedure repairs a damaged or weakened anal sphincter. Surgeon will 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.

Rectopexy

Surgical correction of rectal prolapse, a rectocele will likely reduce or eliminate faecal incontinence.

Sphincter replacement

A damaged anal sphincter can be replaced with an artificial anal sphincter. The device is essentially an inflatable cuff, which is implanted around your anal canal. When inflated, the device keeps your anal sphincter shut tight until you're ready to defecate. To go to the toilet, you use a small external pump to deflate the device and allow stool to be released. The device then reinflates itself.

Sphincter reconstruction (dynamic graciloplasty)

In this surgery doctors take a muscle from the inner thigh and wrap it around the sphincter, restoring muscle tone to the sphincter.

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 have been tried.