Uncontrollable passage of feces; Loss of bowel control; Fecal incontinence; Bowel incontinence
Bowel incontinence is the loss of bowel control, resulting in involuntary passage of feces. This can range from an occasional leakage of stool with the passage of gas to a complete loss of control of bowel movements.
Urinary incontinence, a separate topic, is the inability to control the passage of urine.
Among people over the age of 65, women more frequently experience bowel incontinence, with 13 out of every 1,000 women reporting loss of bowel control.
The most common cause of bowel incontinence, ironically, is constipation. Constipation causes the muscles of the anus and intestines to stretch and weaken. The weakened muscles will prevent the rectal sphincter from tightly closing thus resulting in leakage of stool. Weakened intestinal muscles will further slow down the transit time of the bowels, making it difficult to pass stools and further worsening the constipation.
Chronic stretching of the anal and intestinal muscles can also make the nerves of the anus and rectum less responsive to the presence of stool in the rectum.
The ability to hold stool and maintain continence requires normal function of the rectum, anus, and the nervous system. Additionally, the person must possess the physical and psychological ability to recognize and appropriately respond to the urge to defecate.
Problems with incontinence should be reported to the health care provider. Incontinence is not a hopeless situation. Proper treatment can help the majority of people, and often the problem can be eliminated altogether.
- chronic constipation or impacted stool in the rectum leading to diarrhea and stool leakage around the impacted stool (see encopresis)
- severe diarrhea that overwhelms the ability to control passage of stool
- stress of unfamiliar environment
- decreased awareness of sensation of bowel fullness
- nerve or muscle damage (from stroke, trauma, tumor, or radiation)
- emotional disturbance (psychological)
- gynecological, prostate, or rectal surgery
- severe hemorrhoids or rectal prolapse
- colectomy or bowel resection surgery
- chronic laxative abuse
Treatment of bowel incontinence should begin with identifying the cause of the incontinence and taking measures to correct the dysfunction. There are several measures that can be taken to promote normal bowel function and enhance the tone of the rectal sphincter.
In people with bowel incontinence attributed to diarrhea, medications may be used to control the diarrhea and potentially eliminate the bowel incontinence. Loperamide (imodium) may be used because it has antidiarrheal properties and increases the tone of the rectal muscle. Other antidiarrheal medications that may be used include cholinergic medications (belladonna or atropine) which decrease intestinal secretions and bowel motility, opium derivatives (paregoric or codeine) which increase intestinal tone and decreases bowel motility, and diphenoxylate (lomotil) which decreases bowel motility and slows the movement of stool through the bowel.
Other medications that may be used to control bowel incontinence include medications that reduce the water content in the stools (activated charcoal or Kaopectate), protect the intestinal lining from irritation (amphogel or Pepto-Bismol), or absorb fluid and add bulk to the stools (Metamucil).
Review all medications that you take with your health care provider. Certain medications may cause or increase the frequency of bowel incontinence, especially in the older person. These medication include:
- sedatives and hypnotics
- muscle relaxants
People who experience bowel incontinence despite medical management, may require surgical intervention to correct the dysfunction. Several different surgical options exist, based on the cause of the bowel incontinence and the person’s general condition.
RECTAL SPHINCTER REPAIR
Sphincter repair is performed on people who have an incompetent rectal sphincter as a result of injury or aging. The procedure consists of re-attaching the rectal muscles to tighten the sphincter and increase the capacity of the anus.
GRACILIS MUSCLE TRANSPLANT
In people with loss of nerve function within the rectal sphincter, gracilis muscle transplants have been performed to restore bowel continence (control). The gracilis muscle is taken from the inner thigh and is used to encircle the sphincter, thus providing sphincter muscle tone.
ARTIFICIAL BOWEL SPHINCTER
Some patients may be treated with an artificial bowel sphincter. The artificial sphincter consists of three parts: a cuff that fits around the anal canal, a pressure regulating balloon, and a pump that inflates the cuff. The artificial sphincter is surgically implanted around the rectal sphincter. The cuff remains inflated to maintain continence. The person has a bowel movement by deflating the cuff. The cuff will automatically re-inflate in 10 minutes.
Sometimes a fecal diversion is performed for people who are not amenable to other therapies. A colostomy is created and the stool is diverted out through an abdominal wall stoma. The person will need to continuously wear an ostomy appliance to contain the stool.
Bowel incontinence often occurs as a result of a deceased ability of the rectal sphincter to handle large amounts of liquid stool. Often, simply modifying the diet may reduce the occurrence of bowel incontinence. Alcohol and caffeine intake should be eliminated as they may cause diarrhea and resulting incontinence is some people. Additionally, certain people are unable to digest lactose, a sugar found in most dairy products, and thus develop severe diarrhea after intake of such foods. Also, some food additives such as nutmeg and sorbitol have been shown to cause diarrhea in susceptible people.
Adding bulk to the diet may thicken the stool and decrease the amount of stools. Certain foods thicken the stools, including rice, bananas, yogurt, and cheese. An increase in fiber (30 grams daily) from whole-wheat grains and bran adds bulk to the diet. Additionally, psyllium containing products such as Metamucil can be used to add bulk to the stools.
Enteral feedings (formula tube feedings) often cause diarrhea and bowel incontinence. For diarrhea and/or bowel incontinence that is occurring because of enteral tube feedings, consult your health care provider or dietitian. The rate of the feedings may need to be changed or bulk agents may need to be added to the formula.
Constipation or fecal impaction may also contribute to fecal incontinence. Loss of rectal tone may result in leakage of watery liquid stool around the fecal impaction. Usually once a fecal impaction has developed, laxatives and enemas are of little help. In this case a health care provider will insert one or two fingers into the rectum and break the mass into fragments so that it can be expelled. Measures should be taken to prevent further development of fecal impaction. Fiber should be added to the diet to promote normal stool consistency. Also an adequate intake of fluids and exercise may enhance normal stool consistency.
When a person is frequently incontinent of stool, special external fecal collection devices may be used to contain the stool and protect the skin from breakdown. These devices consist of a drainable pouch attached to an adhesive wafer. This wafer has a hole cut through the center which fits over the anal opening.
Most people who have bowel incontinence due to a lack of sphincter control or decreased awareness of the urge to defecate may benefit from a bowel retraining program and exercise therapies aimed at restoring normal muscle tone. See also- bowel retraining program.
Special care must be taken to maintain bowel control in people who have a decreased ability to recognize the urge to defecate, or impaired mobility that prevents them from independently and safely using the toilet. Assist the person to use the toilet after meals, and promptly respond to the person’s request to use the toilet. If toileting needs are often unanswered, a pattern of negative reinforcement may develop. In this case the urge to defecate is no longer associated with appropriate actions. See also toileting safety.
Call your health care provider if
- there is any incontinence of feces in a child that has been previously toilet trained.
- there is any incontinence of feces in an adult.
- there is any skin irritation or ulceration as a result of fecal incontinence.
What to expect at your health care provider’s office
The health care provider will perform a physical examination, focusing on the abdomen and rectum. A digital exam of the rectum and anus will be performed. The health care provider will insert a lubricated finger into the rectum to evaluate sphincter tone, anal reflexes, and to check for any abnormalities of the rectal area.
Medical history questions documenting bowel incontinence in detail may include:
- Has anything happened recently to cause emotional upset?
- Is the patient confused or disoriented?
- In a child, was he or she previously toilet trained? Did he or she have trouble with toilet training?
- What other symptoms are also present?
- Describe your problem. When does this occur?
- How long has incontinence been a problem?
- How many times does this happen each day?
- Are you aware of the need to defecate before you leak?
- What is the consistency of the stool?
- Describe the amount of stool leakage (discharge, with gas, large amount of stool)?
- What surgeries have you had?
- What injuries have you had?
- What medications do you take?
- Do you drink coffee? How much?
- Do you drink alcohol? How much?
- Describe your usual diet.
Diagnostic tests may include:
- stool culture if person has chronic diarrhea
- blood tests
- barium enema
- defecography (x-ray procedure using a contrast material to visualize the bowel while the person defecates)
- balloon sphincterogram (x-ray procedure using a contrast material to evaluate how well the sphincter contracts)
- anal manometry (measures anal sphincter tone)
- rectal or pelvic ultrasound
by Gevorg A. Poghosian, Ph.D.