Fecal incontinence

WHAT IS FECAL INCONTINENCE?

FECAL INCONTINENCE is the involuntary loss of  gas or liquid stool (called minor incontinence) or the involuntary loss of solid stool (called major incontinence).   6.5 million Americans suffer from fecal incontinence.  It is more commen in women than men predominately due to childbirth and pelvic organ prolapse.  It is more common in older patients but it is not a normal part of aging.  It can have a devastating impact on quality of life with humiliating and embarrassing accidents.  Patients can become socially isolated from family and friends and limit their outtings to be close to a toilet.  There are treatment options available for fecal incontinence and people don’t have to let their suffering go unattended.

WHAT ARE THE CAUSES OF FECAL INCONTINENCE?

  • Damage to the anal sphincter muscles:  The ring like muscle that keeps one from leaking gas, liquid or solid stool is called the anal sphincter.  If this muscle is torn, it is weakened and therefore ineffective enough to squeeze closed and prevent leakage.  Childbirth and hemorrhoid surgeries are the most common causes for this disruption in muscle function
  • Damage to the nerves that innervate the anal sphincter:  The anal sphincter is directed when to squeeze tight to prevent leakage and when to relax to allow for defection via nerves.  There are also separate nerves to sense when the rectum is full to help the patient sense when to head for the toilet.  If either of these nerve sets is damaged, then incontinence may occur.  The nerves can be damaged during childbirth, chronic straining, stroke, diabetes and other chronic medical conditions.
  • Loss of storage capacity: Removal of a portion of the colon, radiation treatment and inflammatory bowel diseases can cause scarring or irritation that make the walls of the rectum stiff and less elastic.  In these instances, the rectum doesn’t stretch to hold the stool.
  • Diarrhea:  Even people that don’t have fecal incontinence can in the face of loose stools.
  • Pelvic Floor Dysfunction: Abnormalities of the pelvic floor can lead to fecal incontinence.  Such abnormalities include decreased perception of rectal sensation, decreased anal pressures, decreased squeeze pressures, impaired anal sensation, rectal prolapse, vaginal prolapse of the rectum, and generalized weakness of the pelvic floor. 

HOW IS FECAL INCONTINENCE DIAGNOSED?

After you have had the routine history and physical, you may need further testing including:

  • Anal manometry:  this test measures the internal pressure in different areas of the lower digestive tract under different conditions. This test can identify several of the different causes of incontinence and may be especially useful in revealing poor tone of the anal sphincters. Manometry can also be used to determine if rectal sensation and rectal reflexes are impaired.
  • Anal Ultrasound or MRI:  An ultrasound or magnetic resonance imaging (MRI) examination of the rectum can reveal abnormalities of the anal sphincters, the rectal wall, and the pelvic muscles that help maintain continence. These tests are generally safe and reliable for identifying structural abnormalities of both the internal and external anal sphincters.
  • Stool tests:  Stool testing may be done to determine if there is an underlying reason for diarrhea (eg, infection).
  • Proctography or Defacography:  This is an xray taken in the process of eliminating stool in order to assess volumes, holding capacity, and completion of evacuation.
  • Proctosigmoidoscopy:  This is a scope of the rectum to directly examine it for signs of disease, tumors, or scarring.
  • Anal electromyography: This is a test of nerve conduction and damage.

WHAT TREATMENT OPTIONS ARE AVAILABLE?

Non-surgical options: 
Dietary changes:  There are some steps that patients can take to help minimize leakage of stool.

  • Avoid foods and drinks that may cause loose or more frequent stools, which can worsen fecal incontinence. These can include dairy products (for people who are lactose intolerant), spicy foods, fatty or greasy foods, caffeinated beverages, diet foods or drinks, sugar-free gum or candy, and alcohol.
  • Eat smaller more frequent meals. In some people, eating a large meal triggers the urge to have a bowel movement, and sometimes cause diarrhea. Eating smaller and more frequent meals can reduce the frequency of bowel movements.
  • Increase fiber in the diet. Fiber increases stool bulk and often improves the consistency of stool. The recommend daily intake of fiber is 25 to 30 grams. The amount of fiber should be increased gradually over a few weeks to reduce the possibility of bloating and gas.

Biofeedback - Biofeedback is a safe and noninvasive way of retraining muscles. During biofeedback training, sensors are used to help the person to identify and contract the anal sphincter muscles, which help maintain continence. This is usually done in a healthcare provider or physical therapist's office.

  • Biofeedback can be successful, although not all studies have confirmed a benefit. The people most likely to benefit from this type of therapy are people who can contract the anal sphincter muscle and have some sensation when they need to have a bowel movement. The effects of biofeedback may begin to decline six months after the initial training, and retraining may be helpful

Medical therapy - Medical therapy includes medication and certain measures that can reduce the frequency of incontinence and firm the stools, which can reduce or eliminate episodes of fecal leakage.

  • Often, basic measures will improve minor incontinence, but more aggressive measures may be needed to control frequent or severe episodes of leakage.
  • Bulking substances - Substances that promote bulkier stools may help control diarrhea by thickening the stools. Methylcellulose (a form of fiber) is one type of bulking substance that is commonly used. Increasing dietary fiber may also help to bulk stool.
  • Medications that reduce stool frequency - The frequency of stools can be reduced with medications that are usually prescribed for diarrhea, such as loperamide (Imodium®) and diphenoxylate (Lomotil®). Loperamide can also increase the tone (tightness) of the anal sphincter muscle.
  • Anticholinergic medications - When taken before meals, anticholinergic medications (such as the prescription drug hyoscyamine) can decrease the incontinence that occurs after meals in some people. The medications work by reducing contractions in the colon.
  • Treatment of impaction - People who have become impacted (when the rectum is full of hard stool) may need to have this stool removed in the office. After disimpaction, the person will be given one or more medications to keep the bowels moving on a regular basis.
  • Defecation programs - When incontinence is related to a disability or mental health condition, a clinician will often recommend a scheduled toileting program. This usually involves sitting on the toilet at a regular time every day, after a meal. Incontinence is less likely to occur if the person empties their bowels regularly.

Anal electrical stimulation - Electrical stimulation involves using a mild electrical current to stimulate the anal sphincter muscles to contract, which can strengthen the muscles over time. The electrical current is applied using a small probe, which the patient inserts inside the rectum for a few minutes every day for 8 to 12 weeks.A controlled trial suggested that electrical stimulation has only a modest benefit, possibly from increasing sensation in the anal area. However, this treatment is inexpensive, non-invasive, and has few to no side effects.

Surgical Options:
  • Sacral nerve stimulation - Electrical stimulation can eliminate leakage in 40 to 75 percent of people whose anal sphincter muscles are intact. An electrode is surgically inserted near a nerve in the sacrum.It is not entirely clear how sacral nerve stimulation works. Experience with this approach is limited. Some people develop complications of the surgery, including pain, device malfunction, or infection, which may require that the device is removed or replaced. At present, this treatment is generally reserved for people with an intact or repaired anal sphincter who have not improved with other treatments.
  • Injectable bulking agent - The gel is injected into the anal sphincter just below the lining that may help build tissue in the anal canal, thereby narrowing the opening of the anus and allowing the patient to better control their anal sphincter. This device was approved the US Food and Drug Administration for clinical use in 2011 in patients ages 18 and up.
  • Surgery - Several different surgical procedures can help alleviate fecal incontinence. Surgical repair can reduce or resolve incontinence, particularly for women who develop a tear in the external anal sphincter during childbirth and in people with injury of the sphincter due to surgery or other causes. Surgery cures fecal incontinence in 80 percent of women with childbirth-related sphincter tears.     
    • In people who have irreparable damage of the sphincters, muscles can be transferred from other areas of the body, usually the leg or buttock, and surgically placed around the anal canal. These muscles mimic the action of the damaged sphincters. Muscle transfer surgery can restore continence in up to 73 percent of people.
    • An alternative to a transferred muscle is a synthetic anal cuff that can be inflated to hold back feces and deflated to allow bowel movements. However, this type of procedure is only performed in specialized centers. Complications can occur even in when these surgeries are performed by experts.
  • Colostomy - Colostomy is a surgical procedure in which the colon is surgically attached to the abdominal wall. Stool is collected in a bag that fits snugly against the skin. This eliminates leakage of stool from the rectum. Variations on the procedure may allow the person to control bowel emptying.Colostomy is usually a last resort, after other treatments have failed. It may also be considered for people with intolerable symptoms who are not candidates for any other therapy.

WHAT ARE SOME EVERYDAY PRACTICAL TIPS FOR FECAL INCONTINENCE SUFFERERS?

There are some steps that patients can take to help minimize leakage of stool.

  • Take a backpack or tote bag containing cleanup supplies and change of clothing wherever you go.
  • Locate public restrooms before you need them.
  • Use the toilet before heading out.
  • Wear disposable undergarments or sanitary pads.
  • Use oral fecal deodorants to add to you comfort level.

WHAT CAN YOU DO FOR ANAL DISCOMFORT?

  • Wash with water either in the shower or on a sitz bath or use moistening towelettes after bowel movements.  Soap can be irritating and drying.
  • Avoid chronic rubbing with toilet paper.  Moistened towelettes may be better.  Air dry or pat dry.
  • Use a barrier moisture cream or non-medicated talcum powder to prevent irritation.
  • Wear cotton underwear and loose clothing.
  • Change soiled clothing as quickly as possible

Fecal incontinence can undermine self-confidence, create anxiety, and lead to social isolation. People who suffer with fecal incontinence should learn as much as possible about their condition and discuss their symptoms honestly with their clinician. Fecal incontinence is a treatable condition; treatment can lessen symptoms in most cases and can often completely cure incontinence

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