Fecal incontinence

Fecal incontinence is the inability to control one's bowels. When one feels the urge to have a bowel movement, they may not be able to hold it until they can get to a toilet, or stool may leak from the rectum unexpectedly.

People who have fecal incontinence may feel ashamed, embarrassed, or humiliated. Some do not want to leave the house out of fear they might have an accident in public. Most try to hide the problem as long as possible, so they withdraw from friends and family. The social isolation may be reduced because treatment can improve bowel control and make incontinence easier to manage.

Prevalence
It affects people of all ages: children as well as adults. Fecal incontinence is more common in women than in men and more common in older adults than in younger adults. It is not, however, a normal part of aging.

In this 1993 British study, it was suggested that fecal incontinence is more common in persons who practice anal sex.

In a more recent study conducted in 1997, no linkage between anal sex and fecal incontinence was found. The study controlled for extraneous variables that the 1993 study did not.

Causes
Fecal incontinence can have several causes:


 * diarrhea
 * pelvic floor dysfunction
 * an extended period without defecation
 * severe muscular strain in the abdominal area, particularly when giving birth
 * 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, e.g. due to surgery
 * Spinal Cord Injury (SCI)

or a combination thereof.

Muscle damage
Fecal incontinence is most often caused by injury to one or both of the ring-like muscles at the end of the rectum called the anal internal and/or external sphincters. The sphincters keep stool inside. When damaged, the muscles are not 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 does an episiotomy, which is a cut in the vaginal area to prevent it from tearing during birth. Hemorrhoid surgery can damage the sphincters as well.

Nerve damage
Fecal incontinence can also be caused by damage to the nerves that control the anal sphincters or to the nerves that sense stool in the rectum. If the nerves that control the sphincters are injured, the muscle does not work properly and incontinence can occur. If the sensory nerves are damaged, they do not sense that stool is in the rectum. The person will not feel the need to defecate until stool has leaked out. Nerve damage can be caused by childbirth, a long-term habit of straining to pass stool, stroke, and diseases that affect the nerves, such as diabetes and multiple sclerosis.

Loss of storage capacity
Normally, the rectum stretches to hold stool until it is voluntarily released. 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 cannot stretch as much and cannot hold stool, and fecal incontinence results. Inflammatory bowel disease also can make rectal walls very irritated and thereby unable to contain stool.

Diarrhea
Diarrhea, or loose stool, is more difficult to control than solid stool that is formed. Therefore, people normally unaffected by fecal incontinence can experience temporary symptoms.

Pelvic floor dysfunction
Abnormalities of the pelvic floor can lead to fecal incontinence. Examples of some abnormalities are decreased perception of rectal sensation, decreased anal canal pressures, decreased squeeze pressure of the anal canal, impaired anal sensation, a dropping down of the rectum (rectal prolapse), protrusion of the rectum through the vagina (rectocele), and/or generalized weakness and sagging of the pelvic floor. Often the cause of pelvic floor dysfunction is childbirth, and incontinence does not show up until the midforties or later.

Diagnosis
The doctor will ask health-related questions and do a physical exam and possibly other medical 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.
 * 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 the stool.
 * Proctosigmoidoscopy allows doctors to look inside the rectum for signs of disease or other problems that could cause fecal incontinence, such as inflammation, tumors, or scar tissue.
 * Anal electromyography tests for nerve damage, which is often associated with obstetric injury.

Treatment
Treatment depends on the cause and severity of fecal incontinence; it may include dietary changes, medication, bowel training, or surgery. More than one treatment may be necessary for successful control since continence is a complicated chain of events.

There are several devices and medications to combat fecal incontinence.

Dietary changes
Food affects the consistency of stool and how quickly it passes through the digestive system. One way to help control fecal incontinence in some persons is to eat foods that add bulk to stool, decreasing the water content of the feces and making it firmer. Also, avoid foods and/or that contribute to the problem. They include foods and drinks containing caffeine, like coffee, tea, and chocolate, which relax the internal anal sphincter muscle. Another approach is to eat foods low in fiber to decrease the work of the anal sphincters. Fruit can act as a natural laxative and should be eaten sparingly.

Individuals affected with fecal incontinence can make dietary adjustments to assist in management of the condition.


 * 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 between certain foods and incontinence. After you identify foods that seem to cause problems, cut back on them and see whether incontinence improves. Foods that typically cause diarrhea, and so should probably be avoided, include
 * caffeine
 * cured or smoked meat like sausage, ham, or turkey
 * spicy foods
 * alcohol
 * dairy products like milk, cheese, and ice cream
 * fruits like apples, peaches, or pears
 * fatty and greasy foods
 * sweeteners, such as sorbitol, xylitol, mannitol, aspartame and fructose, which are found in diet drinks, sugarless gum and candy, chocolate, and fruit juices


 * Eat smaller meals more frequently. In some people, large meals cause bowel contractions that lead to diarrhea. 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 the meals.


 * Eat more fiber. Fiber makes stool soft, formed, and easier to control. Fiber is found in fruits, vegetables, and grains, like those listed below. You'll need to eat 20 to 30 grams of fiber a day, but add it to your diet slowly so your body can adjust. Too much fiber all at once can cause bloating, gas, or even diarrhea. Also, too much insoluble, or undigestible, fiber can contribute to diarrhea. So if you find that eating more fiber makes your diarrhea 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, fiber slow the emptying of the bowels. Examples are bananas, rice, tapioca, bread, potatoes, applesauce, cheese, smooth peanut butter, yogurt, pasta, and oatmeal.


 * Get plenty to drink. You need to drink eight 8-ounce glasses of liquid a day to help prevent dehydration and to keep stool soft and formed. Water is a good choice, but avoid drinks with caffeine, alcohol, milk, or carbonation if you find that they trigger diarrhea.

Over time, diarrhea can rob you of vitamins and minerals. Ask your doctor if you need a vitamin supplement.

Medication
If diarrhea is causing the incontinence, medication may help. Sometimes doctors recommend using bulk laxatives to help people develop a more regular bowel pattern. Or the doctor may prescribe antidiarrheal 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 bowels. In some cases, it 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. Special computer equipment measures muscle contractions as you do exercises--called Kegel exercises--to strengthen the rectum. 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 fecal 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 fecal 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 a while to develop a regular pattern. Try not to get frustrated or give up if it does not work right away.

Surgery
Surgery may be an option for people whose fecal incontinence is caused by injury to the pelvic floor, anal canal, or anal sphincter. Various procedures can be done, depending on the cause of the incontinence. Anal sphincter defects are repaired by performing an overlapping sphincteroplasty. This procedure entails taking the two ends of the damaged muscle and overlapping them around the anal canal to tighten the outlet. This is the most common operation performed for sphincter defects. It is associated with the best long-term outcomes and the fewest complications. Neurogenic causes of incontinence are more difficult to treat surgically. People with severely debilitating loss of control who have not had prior radiation treatment to the pelvis may be candidates for an artificial bowel sphincter. This is a plastic strip filled with water and wrapped around the anal canal to keep it closed. When patients need to defecate, they pump a small device to remove the water and collapse the strip. After defecation, the device is pumped again and the strip is refilled with water. This procedure can be life-changing for many people with refractory incontinence, however due to the nature of the anal canal and the constant stream of bacteria from feces, complication rates can be high. Other less common procedures include replacing anal muscle with muscle from the leg or forearm.

For those individuals who are not candidates for these surgical procedures but whose incontinence is debilitating (i.e. keeping them homebound), a colostomy may be an option to restore them to a normal life. A colostomy is performed by dividing the sigmoid colon then taking the proximal end and bringing it out onto the abdominal wall. The distal end is stapled closed. The colon then empties fecal material into a bag on the abdominal wall. This seemingly drastic procedure gives people the ability to control bowel movements and resume their former lives. A newer and increasingly popular option is the cecostomy, where a permanent connection is made between the cecum and the abdominal wall, allowing the person to clear the colon of stool as needed by flushing water in a large antegrade enema. The passage is typically made with a sealing device designed for use in a gastrostomy or jejunostomy, but the appendix can also be used.

What to do about anal discomfort
The skin around the anus is delicate and sensitive. Constipation and diarrhea or contact between skin and stool can cause pain or itching. Here's what you can do to relieve discomfort:


 * Wash the area with water, but not soap, after a bowel movement. Soap can dry out the skin, making discomfort worse. If possible, wash in the shower with lukewarm water or use a sitz bath. Or try a no-rinse skin cleanser. Try not to use toilet paper to clean up--rubbing with dry toilet paper will only irritate the skin more. Premoistened, alcohol-free towelettes are a better choice.
 * Let the area air dry after washing. If you do not have time, gently pat yourself dry with a lint-free cloth.
 * Use a moisture barrier cream, which is a protective cream to help prevent skin irritation from direct contact with stool. However, talk to your health care professional before you try anal ointments and creams because some have ingredients that can be irritating. Also, you should clean the area well first to avoid trapping bacteria that could cause further problems. Your health care professional can recommend an appropriate cream or ointment.
 * Try using nonmedicated talcum powder or corn starch to relieve anal discomfort.
 * Wear cotton underwear and loose clothes that "breathe." Tight clothes that block air can worsen anal problems. Change soiled underwear as soon as possible.
 * If you use pads or diapers, make sure they have an absorbent wicking layer on top. Products with a wicking layer protect the skin by pulling stool and moisture away from the skin and into the pad.

Emotional considerations
Because fecal incontinence can cause distress in the form of embarrassment, fear, and loneliness, taking steps to deal with it is important. Treatment can help improve the patient's life and emotional state. Seeking medical advice is strictly necessary for sufferers of this disorder. The organizations listed at the end of this article also provide information, opportunities for support and referrals to doctors who specialize in treating fecal incontinence.

Everyday practical tips

 * Take a backpack or tote bag containing cleanup supplies and a change of clothing with you everywhere.
 * Locate public restrooms before you need them so you know where to go.
 * Use the toilet before heading out.
 * If you think an episode is likely, wear disposable undergarments or sanitary pads.
 * If episodes are frequent, use oral fecal deodorants to add to your comfort level.

Fecal incontinence in children
If one's child has fecal incontinence, one needs to see a doctor to determine the cause and treatment. Fecal incontinence can occur in children because of a birth defect or disease, but in most cases it's because of chronic constipation. (see also soiling)

Potty-trained children often get constipated simply because they refuse to go to the bathroom. The problem might stem from embarrassment over using a public toilet or unwillingness to stop playing and go to the bathroom. But if the child continues to hold in stool, the feces will accumulate and harden in the rectum. The child might have a stomachache and not eat much, despite being hungry. And when he or she eventually does pass the stool, it can be painful, which can lead to fear of having a bowel movement.

A child who is constipated may soil his or her underpants. Soiling happens when liquid stool from farther up in the bowel seeps past the hard stool in the rectum and leaks out. Soiling is a sign of fecal incontinence. Try to remember that your child did not do this on purpose. He or she cannot control the liquid stool and may not even know it has passed.

The first step in treating the problem is passing the built-up stool. The doctor may prescribe one or more enemas or a drink that helps clean out the bowel, like magnesium citrate, mineral oil, or polyethylene glycol.

The next step is preventing future constipation. One will play a big role in this part of his or her child's treatment. He or she may need to teach your child bowel habits, which means training your child to have regular bowel movements. Experts recommend that parents of children with poor bowel habits encourage their child to sit on the toilet four times each day (after meals and at bedtime) for 5 minutes. One can give rewards for bowel movements and remember that it is important not to punish his or her child for incontinent episodes.

Some changes in eating habits may be necessary too. One's child should eat more high-fiber foods to soften stool, avoid dairy products if they cause constipation, and drink plenty of fluids every day, including water and juices like prune, grape, or apricot, which help prevent constipation. If necessary, the doctor may prescribe laxatives.

It may take several months to break the pattern of withholding stool and constipation, and episodes of fecal incontinence may reoccur occasionally. The key is to pay close attention to your child's bowel habits. Some warning signs to watch for include


 * pain with bowel movements
 * hard stool
 * constipation
 * refusal to go to the bathroom
 * soiled underpants
 * signs of holding back a bowel movement, like squatting, crossing the legs, or rocking back and forth

Why children get constipated

 * They were potty-trained too early.
 * They refuse to have a bowel movement (because of painful ones in the past, embarrassment, stubbornness, or even a dislike of public bathrooms).
 * They are in an unfamiliar place.
 * They are reacting to family stress like a new sibling or their parents' divorce.
 * They cannot get to a bathroom when they need to go so they hold it. As the rectum fills with stool, the child may lose the urge to go and become constipated as the stool dries and hardens.
 * Laziness

Incontinence clinic
An incontinence clinic is a specially designed toilet facility which is equipped to cater for the needs of children and adults who are incontinent.

Reference
This article is based largely on public domain text from the U.S. government. See:
 * http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/