Bowel incontinence – Illnesses & conditions

Treatment for bowel incontinence depends on underlying cause and the pattern of your symptoms.

Trying the least intrusive treatments first, such as dietary changes and exercise programmes, is often recommended.

Medication and surgery are usually only considered if other treatments haven’t worked.

The various treatments for bowel incontinence are outlined below. 

Continence products

You may find it helpful to use continence products until your bowel incontinence is better controlled. Most continence products are available for free on the NHS.

Anal plugs are one way to prevent involuntary soiling. An anal plug is made of foam and designed to be inserted into your bottom. However, they can be uncomfortable and they’re not really a long term solution.

If the plug comes into contact with moisture from the bowel, it expands and prevents leakage or soiling. Anal plugs can be worn for up to 12 hours, after which time they are removed using an attached string.

Disposable body pads are contoured pads that soak up liquid stools and protect your skin. They can be used in cases of mild bowel incontinence.

Single-use silicone inserts, which form a seal around the rectum until your next bowel movement, are also being investigated as a treatment option for moderate to severe bowel incontinence.

Your local NHS continence service can offer help and advice about continence products, and you don’t usually need a referral from your GP to make an appointment. These clinics are staffed by nurses who specialise in continence treatment.

When you’re out

• Wear trousers or skirts that are easy to undo and have elasticated waistbands rather than buttons.
• Disability Rights UK offers access to 9,000 disabled toilets around the UK with a Radar NKS key. The key costs £4.50 and is only sold to people who require use of toilet facilities due to a disability or health condition.

Dietary changes

Bowel incontinence associated with diarrhoea or constipation can often be controlled by making changes to your diet.

It may be beneficial to keep a food diary to record the effect of your diet on your symptoms.

Diarrhoea

The National Institute for Health and Care Excellence (NICE) has published dietary advice for managing diarrhoea in cases of irritable bowel syndrome. These guidelines can also be applied to people with diarrhoea associated with bowel incontinence.

The advice from NICE includes the following:

• limit fibre intake from wholegrain breads, bran, cereals, nuts and seeds (except golden linseeds)
• avoid skin, pips and pith from fruit and vegetables
• limit fresh and dried fruit to 3 portions a day and fruit juice to 1 small glass a day (make up the recommended ‘5 a day’ with vegetables)
• limit how often you have fizzy drinks and drinks containing caffeine
• avoid foods high in fat, such as chips, fast foods and burgers

Constipation

A high-fibre diet is usually recommended for most people with constipation-associated bowel incontinence. Your GP can tell you if a high-fibre diet is suitable for you.

Fibre can soften stools, making them easier to pass. Foods that are high in fibre include:

• fruit and vegetables
• beans
• wholegrain rice
• wholewheat pasta
• wholemeal bread
• seeds, nuts and oats

Drink plenty of fluids because this can help to soften your stools and make them easier to pass.

Pelvic floor muscle training

Pelvic floor muscle training is a type of exercise programme used to treat cases of bowel incontinence caused by weakness in the pelvic floor muscles.

A therapist, usually a physiotherapist or specialist nurse, will teach you a range of exercises. The goal of pelvic floor muscle training is to strengthen any muscles that may have been stretched and weakened.

You’ll probably be required to carry out the exercises 3 times a day, for 6 to 8 weeks. After this time, you should notice an improvement in your symptoms.

Exercises to try

Check with your health professional before trying these at home.

First, pretend you’re trying to hold in a bowel movement. You should feel the muscles around your anus tighten.

Next, sit, stand, or lie in a comfortable position with your legs slightly apart.

• Squeeze your pelvic floor muscles for as long as you can, then relax. Repeat 5 times.
• Squeeze the muscles as hard as you can, then relax. Repeat 5 times.
• Squeeze the muscles quickly, then relax. Repeat 5 times.

If you find these exercises too difficult, try fewer repetitions at first and build them up. If they get too easy, try doing more repetitions. You can do the exercises without anyone knowing about them, so they should be easy to fit into your daily routine.

Bowel retraining

Bowel retraining is a type of treatment for people with reduced sensation in their rectum as a result of nerve damage, or for those who have recurring episodes of constipation.

There are 3 goals in bowel retraining:

• to improve the consistency of your stools
• to establish a regular time for you to empty your bowels
• to find ways of stimulating your bowels to empty themselves

Changes to your diet usually improve stool consistency (see above).

Establishing a regular time to empty your bowels means finding the most convenient time when you can go to the toilet without being rushed.

Ways to stimulate bowel movements can differ from person to person. Some people find a hot drink and meal can help. Others may need to stimulate their anus using their finger.

Biofeedback

Biofeedback is a type of bowel retraining exercise that involves placing a small electric probe into your bottom.

The sensor relays detailed information about the movement and pressure of the muscles in your rectum to an attached computer.

You’re then asked to perform a series of exercises designed to improve your bowel function. The sensor checks that you are performing the exercises in the right way.

Medication

Medication can be used to help treat soft or loose stools or constipation associated with bowel incontinence.

Loperamide is a medicine widely used to treat diarrhoea. It works by slowing down the movement of stools through the digestive system, allowing more water to be absorbed from the stools. Loperamide can be prescribed in low doses to be taken regularly over a long period of time.

Laxatives are used to treat constipation. They’re a type of medicine that helps you to pass stools. Bulk-forming laxatives are usually recommended. These help your stools to retain fluid. This means they’re less likely to dry out, which can lead to faecal impaction.

Enemas or rectal irrigation

Rectal irrigation or enemas are used when bowel incontinence is caused by faecal impaction and other treatments have failed to remove the impacted stool from the rectum.

These procedures involve a small tube that is placed into your anus. A special solution is then used to wash out your rectum.

Surgery

Surgery is usually only recommended after all other treatment options have been tried.

The main surgical treatments used on the NHS are sphincteroplasty and sacral nerve stimulation. Other treatments – such as tibial nerve stimulation, endoscopic heat therapy and artificial sphincter surgery – can also be used, but their availability on the NHS is limited.

An operation called a colostomy is more widely available on the NHS, but it’s only used if other treatments are unsuccessful.

These treatments are outlined in more detail below.

Sphincteroplasty

A sphincteroplasty is an operation to repair damaged sphincter muscles. The surgeon removes some of the muscle tissue and the muscle edges are overlapped and sewn back together. This provides extra support to the muscles, which makes them stronger.

Sacral nerve stimulation

Sacral nerve stimulation is a treatment used for people with weakened sphincter muscles.

Electrodes are inserted under the skin in the lower back and connected to a pulse generator. The generator releases pulses of electricity that stimulate the sacral nerves, which causes the sphincter and pelvic floor muscles to work more effectively.

At first, the pulse generator is located outside your body. If the treatment is effective, the pulse generator will be implanted deep under the skin in your back.

The most commonly reported complications of the procedure are infection at the site of surgery and technical problems with the pulse generator, which require additional surgery to correct.

See the NICE guidelines on Sacral nerve stimulation for faecal incontinence.

Tibial nerve stimulation

Tibial nerve stimulation is a fairly new treatment for bowel incontinence.

A fine needle is inserted into the tibial nerve just above the ankle and an electrode is placed on the foot. A mild electric current is passed through the needle to stimulate the tibial nerve. It’s not known exactly how this treatment works, but it’s thought to work in a similar way to sacral nerve stimulation.

NICE concludes that the procedure appears to be safe, although there are still uncertainties about how well it works.

See the NICE guidelines on Treating faecal incontinence by stimulating the tibial nerve.

Injectable bulking agents

Bulking agents, such as collagen or silicone, can be injected into the muscles of the sphincter and rectum to strengthen them.

The use of bulking agents in this way is a fairly new technique, so there’s little information about their long-term effectiveness and safety.

You should discuss the possible advantages and disadvantages of this type of treatment in full with your treatment team before deciding whether to proceed.

See the NICE guidelines on Treating faecal incontinence with injectable bulking agents.

Endoscopic heat therapy

Endoscopic radiofrequency (heat) therapy is a fairly new treatment for bowel incontinence.

Heat energy is applied to the sphincter muscles through a thin probe, to encourage scarring of the tissue. This helps tighten the muscles and helps to control bowel movements.

The National Institute for Health and Care Excellence (NICE) recently produced guidelines on this procedure. NICE concluded that the procedure appears to be safe, although there are still uncertainties about how well it works.

As well as the uncertainties surrounding this procedure, it is also expensive. Therefore, it is usually only used on the NHS during clinical trials.

See the NICE guidelines on Treating faecal incontinence using endoscopic radiofrequency therapy.

Artificial sphincter

An artificial sphincter may be implanted if you have bowel incontinence caused by a problem with your sphincter muscles.

This operation involves placing a circular cuff under the skin around the anus. The cuff is filled with fluid and sits tightly around the anus, keeping it closed.

A tube is placed under the skin from the cuff to a control pump. In men, the pump is placed near the testicles, in women it’s placed near the vagina. A special balloon is placed into the tummy, and this is connected to the control pump by tubing that runs under the skin.

The pump is activated by pressing a button located under the skin. This drains the fluid from the cuff into the balloon, so your anus opens and you can pass stools. When you are finished, the fluid slowly refills the cuff and the anus closes.

The use of an artificial sphincter is a relatively new procedure, so there isn’t much good-quality information about its long-term effectiveness and safety.

Possible problems include infection, injury during surgery and the cuff becoming dislodged. In some cases, further surgery is required to correct problems.

See the NICE guidelines on Treating faecal incontinence with an artificial sphincter inserted through a cut in the abdomen.

Colostomy

A colostomy is usually only recommended if other surgical treatments are unsuccessful.

A colostomy is a surgical procedure in which your colon (lower bowel) is cut and brought through the wall of your stomach to create an artificial opening. Your stools can then be collected in a bag, known as a colostomy bag, which is attached to the opening.

Symptoms & Causes of Fecal Incontinence

What are the symptoms of fecal incontinence?

The symptoms of fecal incontinence depend on the type.

• If you have urge fecal incontinence, you will know when you need to pass stool but not be able to control passing stool before reaching a toilet.
• If you have passive fecal incontinence, you will pass stool or mucus from your anus without knowing it.

Some medical experts include streaks or stains of stool or mucus on your underwear—called soiling—as a symptom of fecal incontinence.

When should I see a doctor for fecal incontinence?

You should see a doctor if your fecal incontinence is frequent or severe. Although some people are able to manage mild or infrequent fecal incontinence on their own, you should see a doctor if your fecal incontinence is affecting your quality of life or causing emotional or social distress.

What causes fecal incontinence in adults?

Fecal incontinence has many causes, including digestive tract disorders and chronic diseases. Some causes of fecal incontinence, such as childbirth by vaginal delivery, happen only in women.

Diarrhea

Loose, watery stools from diarrhea fill your rectum quickly and are harder to hold in than solid stools. Diarrhea is the most common risk factor for fecal incontinence for people not staying in hospitals, nursing homes, or other similar institutions. Diarrhea may be caused by digestive tract problems such as

• inflammatory bowel disease
• irritable bowel syndrome
• proctitis

Constipation

Constipation can lead to large, hard stools that are difficult to pass. The hard stools stretch and, over time, weaken the muscles in your rectum. The weakened muscles let watery stools that build up behind the hard stool leak out.

Muscle injury or weakness

If the muscles in your anus, pelvic floor, or rectum are injured or weakened, they may not be able to keep your anus closed, letting stool leak out. These muscles can be injured or weakened by

• surgery to
  • remove cancer in the anus or rectum
  • remove hemorrhoids
  • treat anal abscesses and fistulas
• trauma

Nerve damage

If the nerves that control your anus, pelvic floor, and rectum are damaged, the muscles can’t work the way they should. Damage to the nerves that tell you when there is stool in your rectum makes it hard to know when you need to look for a toilet. Nerves can be damaged by

• a long-term habit of straining to pass stool
• brain injury
• spinal cord injury

Neurologic diseases

Neurologic diseases that affect the nerves of the anus, pelvic floor, or rectum can cause fecal incontinence. These diseases include

• dementia
• multiple sclerosis
• Parkinson’s disease
• stroke
• type 2 diabetes

Loss of stretch in the rectum

If your rectum is scarred or inflamed, it becomes stiff and can’t stretch as much to hold stool. Your rectum can get full quickly, and stool can leak out. Rectal surgery, radiation therapy in the pelvic area, and inflammatory bowel disease can cause scarring and inflammation in your rectum.

Hemorrhoids

Hemorrhoids can keep the muscles around your anus from closing completely, which lets small amounts of stool or mucus to leak out.

Rectal prolapse

Rectal prolapse—a condition that causes your rectum to drop down through your anus—can also keep the muscles around your anus from closing completely, which lets small amounts of stool or mucus leak out.

Physical inactivity

If you are not physically active, especially if you spend many hours a day sitting or lying down, you may be holding a lot of stool in your rectum. Liquid stool can then leak around the more solid stool. Frail, older adults are most likely to develop constipation-related fecal incontinence for this reason.

Childbirth by vaginal delivery

Childbirth sometimes causes injuries to the anal sphincters, which can cause fecal incontinence. The chances are greater if

• your baby was large
• forceps were used to help deliver your baby
• you had a vacuum-assisted delivery
• the doctor made a cut, called an episiotomy, in your vaginal area to prevent the baby’s head from tearing your vagina during birth

Rectocele

Rectocele is a condition that causes your rectum to bulge out through your vagina. Rectocele can happen when the thin layer of muscles separating your rectum from your vagina becomes weak. Stool may stay in your rectum because the rectocele makes it harder to push stool out.

What causes fecal incontinence in children?

For children older than age 4, the most common cause of fecal incontinence is constipation with a large amount of stool in the rectum. When this happens, a child may not be able to sense when a new stool is coming into the rectum. The child may not know that he or she needs to have a bowel movement. A large amount of stool in the rectum can cause the internal anal sphincters to become chronically relaxed, which lets soft stool seep around hard stool in the rectum and leak out.

Birth defects of the anus, rectum, or colon, such as Hirschsprung disease, can cause fecal incontinence in children. These birth defects may weaken pelvic floor muscles or damage nerves in the anus or rectum. Injuries to the nerves in the anus and rectum can also cause fecal incontinence, as can spinal cord injuries and birth defects of the spinal cord.

Fecal incontinence (encopresis) in children

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Fecal incontinence – causes, symptoms, treatment

Contents

1. Introduction
2. Why Encopresis Occurs
3. Causes in adults
4. Classification and stages of development
5. Diagnosis of incontinence
6. Treatment of fecal incontinence
7. Surgical methods
8. Tips for fecal incontinence

Fecal incontinence (encopresis, anal incontinence) is a condition in which the process of passing feces and gases is not controlled by a person. More common in men than in women. The manifestation of encopresis can be caused by trauma and tumor-like processes.

Pathology is primary and secondary. Primary encopresis is a congenital malformation. Acquired occurs due to diseases, injuries and certain conditions.

Why encopresis occurs

Incontinence occurs when there is an imbalance between the central nervous system, the sphincter muscles, and the pelvic floor muscles. In the normal state, they hold feces and gases until the patient’s conscious desire to empty himself.

Prior to conscious exposure, the external sphincter is in good shape, in a closed state. The internal sphincter is not controlled by a person. The ability to control the activity of the external sphincter allows us to avoid uncontrolled defecation in the middle of the night or during the day.

Stimulation of emptying occurs when special receptors are stimulated in the distal part of the rectum. Signals are sent to the brain when the rectal canal is filled with feces.

A person has a reflex, according to which, for the act of defecation, one should sit down. After this, muscle contractions occur in the region of the rectum and abdominal wall, feces are pushed out of the rectal canal.

If it is impossible to empty the intestines right now, then the external sphincter and the muscles between the pubis and the rectum tense up. In this case, the urge to go to the toilet subsides.

With anal incontinence, there is a failure in which feces with gases leave the rectum without the patient’s desire.

Causes in adults

The causes of incontinence can be various bowel diseases, as well as some conditions. The problem occurs when:

• hemorrhoids – in the advanced stages of hemorrhoids, the external sphincter cannot close completely, which leads to leakage of feces. In addition, progressive hemorrhoids lead to a decrease in sphincter tone, which will save encopresis after elimination of hemorrhoidal neoplasms;
• traumatization of the sphincter complex – may occur after surgery or injury. For example, in the treatment of fistulas, removal of hemorrhoids, falling from a height;
• violation of the functioning of nerve receptors – the patient does not feel the filling of the rectal canal, the body loses the ability to keep the external and internal sphincters in good shape. This condition can be caused by childbirth, traumatic brain injury, stroke;
• constipation – stool discharge less than 3 times a week provokes dysfunction of the sphincter muscles, weakening of the holding capacity;
• loss of elasticity of muscle tissue – scarring occurs with Crohn’s disease, surgery, oncology therapy;
• dysfunction of the pelvic muscles – possibly with rectal prolapse, postpartum complications, intestinal hernia, episiotomy in women. When dissecting the perineum, fecal incontinence can occur both immediately after childbirth and several years later;
• prolonged and frequent “patience” – if you often endure going to the toilet for a long period, then the rectal ampulla is stretched, and the external sphincter weakens;
• for spinal injuries.

Mental and neurological disorders can lead to gas and fecal incontinence. For example, schizophrenia, psychosis, neurosis, panic attacks, epilepsy, hysteria.

Also, the cause of incontinence can be benign and malignant neoplasms, gastrointestinal diseases, and digestive disorders.

In old age, encopresis occurs with dementia.

Classification and stages of development

Depending on the method of fecal leakage, there are:

1. Partial incontinence. It occurs with any sudden movement – sneezing, coughing.
2. Incontinence after urge. The patient feels the urge to void, but cannot delay it.
3. Regular incontinence. The call is completely absent. Most often observed in the elderly in serious condition and young children.

The severity is determined by the subjective feelings of the patient. For diagnosis, the Fecal Incontinence Severity Index, the Cleveland Scale, and the Fecal Incontinence Quality of Life Scale are used.

There are three stages of the disease:

• I degree – gas incontinence;
• II degree – gas and liquid stool incontinence;
• III degree – gas incontinence, liquid and hard stools.

According to the localization of the defect, pathology is divided into:

• side wall defect;
• rear wall defect;
• multiple wall defect;
• The entire circle is damaged.

Without determining the cause of encopresis, therapy usually does not give the desired result. Therefore, the main task of the coloproctologist is to identify it.

Incontinence diagnostics

Diagnosis of incontinence includes a survey, a mandatory digital rectal examination and instrumental diagnostic methods.

Survey

During the interview, the doctor listens to complaints and asks clarifying questions. Questions relate to the nature and episodic incontinence, diet, experienced stressful situations, the volume and consistency of the outgoing feces, the presence of an urge to defecate. The doctor is also interested in the symptoms of neurological disorders – episodes of confusion of thoughts, loss of consciousness, disorientation in space and time. Medications taken can affect muscle tone.

Digital rectal examination

The specialist examines the tone of the sphincter complex, the presence of concomitant rectal diseases that could affect it.

To evaluate anal reflux, a doctor performs a cotton swab test. When it comes into contact with the skin of the anus, the latter contracts. If the patient has innervation, then the reaction will be mild or absent.

Instrumentation

Depending on the preliminary diagnosis, to confirm or refute it, the following can be assigned:

• sigmoidoscopy;
• Ultrasound of the rectum;
• electromyography;
• proctography;
• MRI of the pelvis;
• anorectal manometry;
• colonoscopy.

In preparation for hospitalization, additional blood and urine tests are prescribed.

Treatment of fecal incontinence

Treatment for fecal incontinence can be conservative or surgical.

Conservative therapy

Conservative therapy is aimed at strengthening the pelvic and rectal muscles, eliminating discomfort, changing the diet and lifestyle, and taking medications.

Supply correction

Diet therapy is aimed at normalizing intestinal motility, eliminating constipation and disorders, and reducing stool volume.

So, with encopresis, the following are removed from the diet:

• coffee;
• whole milk;
• nutmeg;
• alcohol;
• spices;
• fatty cheeses;
• sugar substitutes;
• carbonated drinks.

Completely refuse or minimize: citrus fruits, lard, fatty meats and fish, smoking.

The diet should be low-fat dairy products, cereals, bran, fruits and vegetables that do not cause increased gas formation and do not provoke increased peristalsis.

Nutrition should be varied and fractional (up to 6 times) – in small portions with equal intervals of time between meals.

Patients are advised to keep a stool and nutrition diary. So you can calculate the products that provoke incontinence.

Medical treatment

The group of drugs prescribed will depend on the cause of encopresis.

So, if incontinence is caused by neurological and mental pathologies, then the patient is prescribed tranquilizers and sedatives.

If the cause of incontinence is frequent disorders, then drugs are prescribed to reduce the amount of water in the feces, drugs with opium derivatives, drugs with atropine and belladonna. They reduce the production of intestinal secretions, slow down peristalsis and increase muscle tone.

Physical exercise

Kegel exercises are effective for strengthening the sphincter and pelvic floor muscles.

A simple complex can be carried out anywhere and at any convenient time. It includes alternate contraction and relaxation of the sphincter, protrusion and retraction of the abdominal cavity, tension and relaxation of the pelvic muscles.

Patients undergoing rehabilitation after a stroke are shown restorative exercise therapy, which allows you to return or improve fine motor skills. The development of fine motor skills accelerates the process of regeneration of brain damage, creates new neural connections.

Biofeedback therapy

The essence of the technique is to strengthen the muscles using an expanding balloon, which is inserted into the rectum. Exercise must be done daily. In advanced form, the disease is ineffective.

Injections

One of the complications after removal of hemorrhoids is fecal incontinence. It occurs after the removal of deformed cavernous bodies, which perform shock-absorbing and retaining fecal functions.

Injection therapy consists in the introduction of special fillers or other gel-like substances into the thickness of the external sphincter. Thus, artificial “pillows” are created that replace the remote nodes and allow the anal canal to close tightly.

RF ablation

The essence of the method is the effect of electric current on the muscle layer of the sphincter. As a result, the process of scarring of muscle tissue occurs. The procedure is performed under internal anesthesia.

Surgical techniques

If minimally invasive treatment methods and conservative therapy did not help, then the patient is recommended sphincteroplasty. Often it is performed in combination with the removal of hemorrhoidal neoplasms to prevent the occurrence of encopresis in the future. The essence of the operation is the surgical restoration of the damaged muscle.

According to clinical indications, an operation to install an artificial sphincter can be performed. It allows you to keep the anus closed. When emptying, the patient releases air from the cuff.

In particularly difficult cases, patients are shown the installation of an intestinal stoma (colostomy bag). Modern devices are securely fixed and retain an unpleasant odor. A few months after the operation, the patient returns to his usual activity.