Faecal incontinence


Faecal incontinence is the inability to control your bowels. When you feel the urge to have a bowel movement, you may not be able to hold it until you get to a toilet. Or stool may leak from the rectum unexpectedly, sometimes while passing gas.

Faecal incontinence affects people of all ages - children and adults. Faecal incontinence is more common in women and older adults, but it is not a normal part of ageing.

Loss of bowel control can be devastating. People who have faecal incontinence may feel ashamed, embarrassed, or humiliated. Some don’t want to leave the house as they fear having an accident in public. Most try to hide the problem as long as possible, leading them to withdraw from friends and family. This social isolation is unfortunate but may be reduced with treatment that improves bowel control and makes incontinence easier to manage.

What causes faecal incontinence?

Faecal incontinence can have several causes:

  • constipation
  • damage to the anal sphincter muscles
  • damage to the nerves of the anal sphincter muscles or the rectum
  • loss of storage capacity in the rectum
  • diarrhoea
  • pelvic floor dysfunction

Constipation is one of the most common causes of faecal incontinence. Constipation causes large, hard stools to become lodged in the rectum. Watery stool can then leak out around the hardened stool. Constipation also causes the muscles of the rectum to stretch, which weakens the muscles so they can't hold stool in the rectum long enough for a person to reach a bathroom.

Muscle damage
Faecal incontinence can be caused by injury to one or both of the ring-like muscles at the end of the rectum called the anal internal and external sphincters. The sphincters keep stool inside. When damaged, the muscles aren't strong enough to do their job and stool can leak out. In women, the damage often happens when giving birth. The risk of injury is greatest if the doctor uses forceps to help deliver the baby or performs an episiotomy, which is a cut in the vaginal area to prevent it from tearing during birth. Haemorrhoid surgery can also damage the sphincters.

Nerve damage
Faecal incontinence can be caused by damage to the nerves that control the anal sphincters or the nerves that sense stool in the rectum. If the nerves that control the sphincters are injured, the muscles don't work properly and incontinence can occur. If the sensory nerves are damaged, they don't sense that stool is in the rectum so you won't feel the need to use the bathroom until stool has leaked out. Nerve damage can be caused by childbirth, a long-term habit of straining to pass stool, stroke, physical disability due to injury, and diseases that affect the nerves such as diabetes and multiple sclerosis.

Loss of storage capacity
Normally, the rectum stretches to hold stool until you can get to a bathroom. But rectal surgery, radiation treatment, and inflammatory bowel disease can cause scarring that makes the walls of the rectum stiff and less elastic. The rectum then can't stretch as much to hold stool and the result can be faecal incontinence. Inflammatory bowel disease also can irritate rectal walls, making them unable to contain stool.

Diarrhoea, or loose stool, is more difficult to control than solid stool because with diarrhoea the rectum fills with stool at a faster rate. Even people who don't have faecal incontinence can leak stool when they have diarrhoea.

Pelvic floor dysfunction
Abnormalities of the pelvic floor muscles and nerves can cause faecal incontinence. Examples include:

  • impaired ability to sense stool in the rectum
  • decreased ability to contract muscles in the anal canal to defecate
  • dropping down of the rectum, a condition called rectal prolapse
  • protrusion of the rectum through the vagina, a condition called rectocele
  • general weakness and sagging of the pelvic floor

Childbirth is often the cause of pelvic floor dysfunction, and incontinence usually doesn't appear until the mid-forties or later.

How is faecal incontinence diagnosed?

Doctors understand the feelings associated with faecal incontinence, so you can talk freely with your doctor. The doctor will ask some health-related questions, do a physical exam, and possibly run some medical tests. Your doctor may refer you to a specialist, such as a gastroenterologist, proctologist, or colorectal surgeon.

The doctor or specialist may conduct one or more 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. Magnetic resonance imaging (MRI) is sometimes used to evaluate the sphincter.
  • 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 it.
  • Proctosigmoidoscopy allows doctors to look inside the rectum and lower colon for signs of disease or other problems that can cause faecal incontinence, such as inflammation, tumours, or scar tissue.
  • Anal electromyography tests for nerve damage, which is often associated with injury during childbirth.

 How is faecal incontinence treated?

Effective treatments are available for faecal incontinence and can improve or restore bowel control. The type of treatment depends on the cause and severity of faecal incontinence; it may include dietary changes, medication, bowel training, or surgery. More than one treatment may be necessary for successful control because continence is a complicated chain of events.

Dietary Changes
Food affects the consistency of stool and how quickly it passes through the digestive system. If your stools are hard to control because they are watery, you may find that eating high-fibre foods adds bulk and makes stool easier to control. But people with well-formed stools may find that high-fibre foods act as a laxative and contribute to the problem. Foods and drinks that may make the problem worse are those containing caffeine—like coffee, tea, or chocolate—which relaxes the internal anal sphincter muscles.

You can adjust what and how you eat to help manage faecal incontinence.

  • Keep a food diary.
    List what you eat, how much you eat, and when you have an incontinent episode. After a few days, you may begin to see a pattern involving certain foods and incontinence. After you identify foods that seem to cause problems, cut back on them and see whether incontinence improves. Foods and drinks that typically cause diarrhoea, and so should probably be avoided, include
    • drinks and foods containing caffeine
    • cured or smoked meat such as sausage, ham, or turkey
    • spicy foods
    alcoholic beverages
  • dairy products such as milk, cheese, or ice cream
  • fruits such as apples, peaches, or pears
  • fatty and greasy foods
  • sweeteners, such as sorbitol, xylitol, mannitol, and fructose, which are found in diet drinks, sugarless gum and candy, chocolate, and fruit juices

Eat small meals more frequently. In some people, large meals cause bowel contractions that lead to diarrhoea. You can still eat the same amount of food in a day, but space it out by eating several small meals.

Eat and drink at different times. Liquid helps move food through the digestive system. So if you want to slow things down, drink something half an hour before or after meals, but not with meals.

Eat the right amount of fibre.For many people, fibre makes stool soft, formed, and easier to control. Fibre is found in fruits, vegetables, and grains. You need to eat 20 to 30 grams of fibre a day, but add it to your diet slowly so your body can adjust. Too much fibre all at once can cause bloating, gas, or even diarrhoea. Also, too much insoluble, or indigestible, fibre can contribute to diarrhoea. If you find that eating more fibre makes your diarrhoea worse, try cutting back to two servings each of fruits and vegetables and removing skins and seeds from your food.

Eat foods that make stool bulkier. Foods that contain soluble, or digestible, fibre slow the emptying of the bowels, including bananas, rice, tapioca, bread, potatoes, applesauce, cheese, smooth peanut butter, yogurt, pasta, and oatmeal.

Get plenty to drink. Drink eight glasses of liquid a day to help prevent dehydration and keep stool soft and formed. Water is a good choice. Avoid drinks with caffeine, alcohol, milk, or carbonation if you find they trigger diarrhoea. 

Over time, diarrhoea can keep your body from absorbing vitamins and minerals. Ask your doctor if you need a vitamin supplement.

If diarrhoea is causing your incontinence, medication may help. Sometimes doctors recommend using bulk laxatives to help people develop a more regular bowel pattern. Or the doctor may prescribe antidiarrhoeal medicines such as loperamide or diphenoxylate to slow down the bowel and help control the problem.

Bowel Training
Bowel training helps some people relearn how to control their bowel movements. In some cases, bowel training involves strengthening muscles; in others, it means training the bowels to empty at a specific time of day.

  • Use biofeedback. Biofeedback is a way to strengthen and coordinate the muscles and has helped some people with incontinence. Special computer equipment measures muscle contractions while you do exercises - called Kegels - to strengthen the rectum and improve rectal sensation. These exercises work muscles in the pelvic floor, including those involved in controlling stool. Computer feedback about how the muscles are working shows whether you're doing the exercises correctly and whether the muscles are getting stronger. Whether biofeedback will work for you depends on the cause of your faecal incontinence, how severe the muscle damage is, and your ability to do the exercises.
  • Develop a regular pattern of bowel movements. Some people - particularly those whose faecal incontinence is caused by constipation - achieve bowel control by training themselves to have bowel movements at specific times during the day, such as after every meal. The key to this approach is persistence - it may take awhile to develop a regular pattern. Try not to get frustrated or give up if it doesn't work right away.

Surgery to repair the anal sphincter may be an option for people who have not responded to dietary treatment and biofeedback and for those whose faecal incontinence is caused by injury to the pelvic floor, anal canal, or anal sphincter.

People who have severe faecal incontinence that doesn't respond to other treatments may benefit from injection of bulking agents in the anus or nerve stimulation in the lower pelvic area.

A colostomy may be indicated for people with severe faecal incontinence who haven't been helped by other procedures. This procedure involves disconnecting the colon and bringing one end through an opening in the abdomen - called a stoma - through which stool leaves the body and is collected in a pouch. The colostomy may be temporary or permanent.

Source: National Digestive Diseases Information Clearinghouse (NDDIC)

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