Faecal incontinence (bowel incontinence)

Bowel incontinence, also called faecal (fecal) incontinence or anal leakage, is the inability to control the bowels, resulting in the unplanned loss of liquid stool (diarrhoea), solid faeces or flatulence (wind). It is different to having sudden-onset (short-term) diarrhoea .

It is difficult to know how common bowel incontinence is, but various research studies suggest that about 10% of adults soil their underwear regularly (British Medical Journal2010;340:1350-5).

What you can do about bowel (faecal) incontinence

Firstly, special thanks to everyone who has provided feedback about how to get on with your life when you have this problem. Some of your suggestions are mentioned here. As one person wrote, ‘At the end of the day, it’s a bodily reaction which is out of your control. If you mess, just laugh it off, clean up, and get on with your day. It doesn’t mean you are dirty, stupid or a kid, you’re just unfortunate for having such a time- consuming illness’.

Think about what and when you eat. You may have noticed that eating stimulates the urge to pass faeces, so changing the timing of your meals and their size may help to reduce the possibility of anal leakage. For some people, eating more fibre to bulk up the faeces helps (British Medical Journal 2010;340:1350-5). Look at our constipation section for information. Other people find that this makes the problem worse, and that a low-fibre diet is better for them.

Pads, wipes and underwear. It makes sense to wear a protective pad, or to carry spare underwear and wet wipes. It may also be useful to carry a spare long-sleeved top to wrap around your hips if you do have an accident. Don’t let the fear of faecal leakage prevent you from swimming. A special undergarment is available, worn next to the skin under your swimsuit (see Useful contacts).

Sphincter exercises. There are exercises that will strengthen the anal muscles. Look at the website of St Mark’s Hospital UK, listed in the Useful contacts. It has a leaflet (Anal Sphincter Exercises for Leakage) explaining how to do these exercises.

Bowel training. It may help if you try to empty your bowels at a specific time every day, for example first thing in the morning or after your evening meal. Over time this will make your bowel movements more predictable and give you greater control over when you need to go to the toilet. For sudden urges, wait as long as you can before sitting down to empty your bowels, gradually increasing the amount of time you wait. You should soon find it easier to hold on for longer.

Loperamide is a medication that prevents the bowel muscle squeezing too strongly, and makes the faeces more solid. It can be bought from pharmacies. It would not be advisable to take it all the time, but it is very useful for occasions where you might be particularly worried about leakage from the bowel.

Gastroenterology and hepatology > Fecal incontinence: treatment options

  • Fecal incontinence is the inability to control the bowels, with unwanted or unplanned loss of stool (feces) or flatulence (wind). The first step is to treat any underlying disorder or problem (e.g. medication, toilet access or lack of activity/exercise) that may be contributing to fecal incontinence or constipation.
  • Check your diet – avoid anything that makes the consistency of your feces looser; increase the amount of natural fiber and avoid artificial fibers and caffeine. In addition, eat smaller meals and drink before or after meals, but not during, to help slow things down.
  • Bowel training and exercises for the pelvic floor muscle and anal sphincter may help to restore muscle strength. A pressure-sensitive anal probe or surface patch electrodes can help you to practice muscle contractions (biofeedback). Electrical stimulation of the anal sphincter may also be helpful.
  • Medications to slow bowel movements, treat diarrhea, or soften or decrease the water content in stools can be used on an as-needed basis. They may require a physician prescription.
  • Neuromodulation techniques can help with symptoms when there is no anal sphincter defect present. Percutaneous tibial nerve stimulation is a non-surgical treatment that can be performed in the office/clinic. Sacral nerve stimulation involves implantation of the stimulator in the buttocks to send continuous impulses to the nerves.
  • Surgical interventions include anal sphincter repair (sphincteroplasty); artificial sphincter and injection of bulking agents to increase the size of the anal sphincter. A colostomy can be a temporary or permanent treatment of last resort.

What your doctor can do about bowel (faecal) incontinence

Investigation. Your doctor will try to work out what the cause is. There are many reasons why people become incontinent and very often the cause is a combination of factors. Working out when and how the incontinence occurs can help to narrow down the causes. Therefore, before seeing the doctor, you may wish to keep a bowel diary for a week, listing when you are troubled by the leakage. The UK’s Bladder and Bowel Foundation has a good example of a bowel diary that you can download.

The doctor will examine you. This will involve a rectal examination to feel the sphincter muscles and look for a rectocoele (rectal prolapse – in women, this is a bulging of the rectum into the back wall of the vagina; in men [extremely rare] the protrusion is usually backwards rather than forwards). Further tests may include colonoscopy, CT scan, pressure testing of the sphincter (anorectal physiology), ultrasound scan of the sphincter muscle or a dye (contrast) test, also called a proctogram, which shows how you pass faeces.

The treatment for incontinence depends on the cause and therefore should be discussed with your doctor before trying any method.

Conservative measures. Often, bowel incontinence will respond to simple measures such as making the stool firmer (see ‘What you can do’ above) and by changes in medication. Physiotherapy in the form of biofeedback can also be very effective in some cases. Rectal irrigation can also be effective in certain cases. This involves the insertion of a tube into the rectum to wash the faeces out with water. This procedure usually needs careful training to perform it safely, so it must be undertaken with close medical supervision.  The majority of people will respond to conservative measures and will not need any further treatment.

Injectable bulking agents. If the anal muscles are weak, injections of ‘bulking agents’ into the wall of the anus may help, but these injections have to be done by a specialist doctor and it is uncertain how effective the treatment is (British Journal of Surgery 2005;92:521–7).

Neuromodulation. For major incontinence, percutaneous tibial nerve stimulation (PTNS) or sacral nerve stimulation is a possibility. PTNS is a non-surgical technique in which a small needle electrode is inserted into the tibial nerve just above the ankle, and impulses travel to the nerves that control bowel function. The procedure is quite new and there is limited information about how well it works. Sacral nerve stimulation involves insertion of electrodes into the lower back, attached to a pulse generator, and is an expensive procedure. A surgical operation is a last resort and may not be successful.

Urology and genitourinary medicine > Percutaneous tibial nerve stimulation

  • Percutaneous tibial nerve stimulation (PTNS) is a non-surgical treatment for overactive bladder (OAB) for symptoms of urinary urgency, frequency or incontinence; in some regions it is also used to treat fecal incontinence.
  • PTNS is used when patients do not want to take, or have had side effects from, drugs, or when other forms of treatment have not worked.
  • PTNS is delivered in the office/clinic setting by the Urgent®PC neuromodulation system, which consists of a stimulator, lead set, needle electrode and an adhesive surface electrode (grounding pad). It is the only device available to deliver this therapy via the tibial nerve.
  • The patient is comfortably seated, with the leg elevated and supported. A small, thin needle electrode is inserted near the tibial nerve at a 60° angle, and a surface electrode (grounding pad) is placed near the arch of the foot. The lead wire is connected to the needle and plugged in to the low-voltage stimulator. The mild stimulation impulse travels along the tibial nerve to the sacral nerve plexus – the nerves in the pelvis that control bladder function.
  • Each treatment lasts for 30 minutes and is relatively painless. Patients describe a sensation of ‘tingling’ or ‘pulsing’. A series of 12 treatments are given, typically once a week. Further maintenance therapy is then tailored to the patients needs.
  • Studies report an improvement in 60–80% of patients, with changes in symptoms typically occurring 6–8 weeks after starting treatments. No serious side effects have been reported to date.

Sphincter surgery. If tests on your sphincter muscles (usually performed after referral to hospital) show there is a gap (defect) in the muscles, then surgery is sometimes recommended in the form of a sphincter repair. This can be quite a difficult decision to make; success of this operation depends on many factors. Therefore, a specialist will discuss the operation with you carefully before any decisions are made.

Causes of bowel (faecal) incontinence

Diet is the first thing to check. Anything that makes the consistency of the faeces more runny, such as a heavy intake of beer, will make it more difficult for you to hold them in. Rhubarb, figs, prunes and plums all contain a natural laxative, and excessive doses of vitamins and minerals (vitamin C, magnesium, calcium) can worsen leakage of faeces. In some people, caffeine loosens the faeces, so it might be a good idea to reduce your intake of coffee or other caffeinated products (e.g. energy drinks, cola).

Olestra, used in some ‘slimming’ foods, has gained unwelcome publicity for this reason. It is an artificial mixture of fats, none of which can be digested or absorbed. Instead, it goes straight along the gut and is passed out at the other end. This means that the faeces are runny and slippery with fat, and soiled underwear can result. Some snack foods (e.g. some crisps) contain olestra, but the amount in the snacks is too small to cause a problem.

Some chewing gums contain sorbitol as a sugar-free sweetener. Sorbitol has a laxative effect, so chewing large amounts of sugar-free gum will make your faeces runny (British Medical Journal 2008;336:96–7).

Anything which makes you pass more wind makes leakage more likely. This is because the anus has to relax to let the wind out, and some faecal material may be propelled out at the same time. Beans, cabbage, sprouts and some spices (such as chilli) commonly cause this problem.

Irritable bowel syndrome is the other common cause. In irritable bowel syndrome (also known as IBS), the bowel muscle squeezes strongly, so that it may be difficult to hold the faeces in. If you have abdominal pain as well as leakage of faeces, then IBS is a strong possibility. The pain of IBS can occur anywhere in the abdomen, but is usually felt low down on the right or left side. Passing wind or opening the bowels often relieves it. People with IBS often have to rush to the toilet, and some leakage is common. There is also often a ‘morning rush’ – the bowels have to be opened urgently several times on rising and after breakfast.

Gastroenterology and hepatology > Irritable bowel syndrome

  • Irritable bowel syndrome is a very common condition caused by abnormal contractions of the muscles in the large intestine and increased sensitivity of the bowel to the presence of gas and movement. It appears to be made worse by stress.
  • Symptoms include recurring, cramp-like or colicky abdominal pain and irregular bowel movements, from diarrhoea to constipation.
  • The symptoms are not usually severe, and may disappear without treatment for periods ranging from days to years.
  • Irritable bowel syndrome can usually be diagnosed without specialized investigations, but if there is any doubt, the colon can be examined using barium enema or colonoscopy.
  • Modifying your diet can relieve symptoms. There are no specific foods that make irritable bowel syndrome worse in everyone, though diets containing very large quantities of roughage (fibre) may increase susceptibility to abdominal bloating and wind. Ususally, patients adjust their diet according to their own experiences or with help from dieticians.
  • If symptoms persist, your doctor may prescribe bulking agents, or else tablets that alter the movement of the bowel, prevent muscle spasm or reduce the bowel’s sensitivity to the presence of gas and to muscle movements.

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