Do you constantly worry about soiling your pants unexpectedly when you are in your home or out in public? This condition, medically known as fecal incontinence, is a prevalent problem that can be embarrassing and upsetting.
But what causes this bowel condition to arise in the first place? Plus, how to tell if you actually have fecal incontinence? This article focuses on all the in-depth information about the various symptoms and causes of fecal incontinence. In addition, we have compiled brief descriptions of the types, risk factors, complications, and management of fecal incontinence to help you understand your bowel condition better.
However, note that this article does not encourage self-diagnosis and self-treatment and is only meant for informative purposes. If you or someone you know suffers from fecal incontinence, it is best to consult a healthcare specialist to receive an accurate diagnosis and on-time treatment.
Fecal Incontinence: An Overview
Fecal incontinence, as the name suggests, is a condition that affects a person’s normal bowel movements. While fecal incontinence is the widely used term, the condition is also commonly known by names such as bowel incontinence, encopresis, anal incontinence, anorectal incontinence, and accidental bowel leakage. All these terms would be used interchangeably throughout the article while describing the condition of fecal incontinence.
To describe bowel incontinence in simple words, it is the accidental or involuntary leakage or passing of fecal matter due to the inability to control the bowel movement process.
The problem of fecal incontinence is not typically seen as a disease but is usually an indication of an underlying issue or disorder. Its range of severity could be anywhere from the frequent involuntary passage of flatus to a more severe complete loss of bowel control followed by the complete evacuation of stool or feces from the rectum.
No matter how severe the fecal incontinence is, the issue can become quite embarrassing for the affected individual, significantly impacting their quality of life and causing them to withdraw from their usual activities. In accidental bowel leakage, the fecal matter passed involuntarily by the patient can either be a solid or liquid stool or mucus from the anal orifice.
As mentioned earlier, fecal incontinence can be a result of an underlying cause. A few most commonly reported causes for this bowel control disorder include constipation, diarrhea, and damage to the surrounding muscles or associated nerves. Other underlying problems or disorders can also lead to the development of bowel incontinence, all of which will be discussed in detail in the section on causes below.
When assessed in the early stages, Fecal incontinence is usually easily treatable and can be reversed to normal if proper management and care are followed. Upon consultation, followed by a thorough history, physical examination, and appropriate diagnostic tests, your healthcare specialist would recommend a treatment based on your bowel incontinence’s severity. The treatment can be a simple dietary change approach, bowel training, pharmacological approach, or surgical route that might be recommended in severe cases.
Fecal incontinence is a prevalent bowel control condition and a major matter of concern that significantly affects various age groups worldwide. However, similar to the problem of urinary incontinence, the social stigma that surrounds bowel incontinence causes the cases to be underreported. It is why an exact statistical analysis result for how common fecal incontinence is cannot be obtained.
According to statistical analysis, the estimated prevalence of fecal incontinence ranges from 2% to 21% and primarily depends on age. An estimated 7% of bowel incontinence cases are reported in women aged 30 years or younger. This estimated percentage of prevalence is observed with an increase of 22% in women aged 60 to 69, that is, their seventh decade of life.
The condition of fecal incontinence is also prevalent in geriatric patients. According to statistics, bowel issues like accidental bowel leakage are reported in 25% to 35% of geriatric patients living in nursing homes and 10% to 25% of those that are hospitalized.
Summing up, the health concern of fecal incontinence is more common with advancing age. It is also essential to mention that this bowel condition is more prevalent in women than men due to the physiological changes following childbirth and menopause. Bowel or fecal incontinence is also seen in children of normal toileting age, called encopresis.
Types Of Fecal Incontinence
In general, fecal incontinence is classified into three subtypes that are as follows:
Urge Fecal Incontinence
The urge type of fecal incontinence refers to the accidental leakage of stool due to the inability to control the sudden need to defecate. The affected individual is unable to retain stool and leaks it accidentally before reaching the toilet. The sensation is preserved and is felt as sudden strong urges that become extremely hard for the person to control, leading to the involuntary leakage of fecal matter. It usually occurs due to the dysfunction of the anal sphincter or the rectum’s inability to hold the feces.
Passive Fecal Incontinence
The passive type of fecal incontinence is the accidental leakage of fecal matter unknowingly. In this type of accidental bowel leakage, the affected individual has no awareness or cannot sense their rectum being full and has no prior feeling for defecating. Passive fecal incontinence typically occurs due to the dysfunction of the anal sphincter or anorectal reflexes or, more commonly, due to an underlying neurological disease.
As the name suggests, fecal seepage refers to the undesired or accidental leakage of fecal matter after a normal bowel movement. The affected individual usually observes stool in the lower clothing after going to the toilet to defecate with normal continence.
Symptoms Of Fecal Incontinence
So, how to tell if you have fecal incontinence? The symptoms of bowel or fecal incontinence depend upon the affected person’s type of incontinence. In general, an individual’s bowel condition is termed fecal incontinence if:
- Fecal matter leaks out during flatulence, that is while passing gas.
- The affected individual accidentally leaks stool while doing any physical activity that exerts their abdominal muscles, such as coughing or lifting objects.
- Stool stains or fecal matter is observed in the underwear after eliminating a normal bowel movement before.
- Other bowel conditions accompany fecal incontinence, such as constipation, diarrhea, bloating, or gas.
However, according to the types of fecal incontinence, the following symptoms can be seen:
- An individual with urge fecal incontinence will feel frequent sudden urges to go to the toilet to defecate. But these sudden urges become uncontrollable by the time they reach the bathroom, resulting in accidental leakage of fecal matter.
- If the individual has passive fecal incontinence, they will leak fecal matter involuntarily without knowing. Their body does not sense when the rectum is full and hence, defecate accidentally at unwanted times.
If you notice these symptoms, consult your healthcare professional for an accurate assessment and on-time treatment.
What Causes Fecal Incontinence?
As mentioned previously, fecal incontinence is not typically seen as a disease but is usually a symptom or an indication of underlying pathology or injury. A variety of causative agents can be the reason behind the development of fecal incontinence in an individual. A single cause can be the sole reason for the incontinence, or a combination of causes might underlie the bowel condition. Some of the most common etiologies or causes of fecal incontinence include the following:
Recurrent Constipation Or Diarrhea
With frequent diarrhea or constant constipation, the muscles of the two anal sphincters and the rectum become weak, causing the fecal matter to leak out involuntarily as the rectum’s capacity to hold the stool reduces.
Diarrhea usually results from irritable bowel syndrome (IBS) or gastrointestinal infections. The loose stools become harder for the weakened sphincters to retain; hence, leakage occurs more rapidly.
On the other hand, constipation can precipitate due to severe dehydration or lack of fiber intake, causing the stools to become hardened. With chronic constipation, the hard stool mass or impacted stool formed in the rectum does not excrete out even with applying intra-abdominal pressure. This lodged mass of fecal matter stretches the muscles of the intestines and rectum, causing them to weaken. In turn, minute space is created around the impacted stool, and the watery feces formed farther up the gastrointestinal tract move around it and then leak out from the anal orifice.
The hardened impacted stool can also damage the surrounding rectal nerves, further reducing the rectum’s stool-holding function and leading to the precipitation of bowel incontinence.
Pelvic floor muscles that surround the rectum and anus can become damaged during a complex vaginal delivery when an episiotomy or a small incision is made between the tissue of the vaginal opening and the anal orifice to facilitate childbirth. If the cut extends or is made deeper, the underlying muscles become damaged and tear the anal opening. This makes it difficult for the individual to retain feces, resulting in fecal incontinence.
Other rectal or anal surgery forms that damage the anorectal ring (the internal and external sphincter muscles and the puborectalis muscle) also cause bowel incontinence.
Due to severe muscle damage or weakening of the pelvic floor during vaginal childbirth or severe constipation, the rectum slips down into the anal region. This condition is known as rectal prolapse and is one of the leading causes of fecal incontinence.
The dropping of the rectum into the anus stretches the rectal sphincter, exerting pressure on the surrounding rectal nerves. The pressure, in turn, decreases the control of the sphincter muscles, leading to the involuntary leakage of fecal matter from the anal orifice. Rectal prolapse usually does not heal on its own and requires surgery to be treated.
Rectocele, also known as posterior vaginal prolapse, is another pelvic floor prolapse condition that typically affects women. In this type of pelvic floor prolapse, the connective tissue between the vaginal wall and the rectum weakens. Upon an increase in intra-abdominal pressure, the rectum drops down and sags into the vagina.
In severe cases of rectocele, the prolapsed rectum can also protrude out from the vaginal opening. The condition of the rectocele can cause the stool to stay inside the rectum, causing rectal discomfort and creating strong urges to defecate. The stool retained in the rectocele might cause smearing and seep out of the anus.
Anus-related surgical complications, difficult vaginal delivery, severe constipation, and spinal cord injury can damage the rectal nerves and cause fecal incontinence. Moreover, pre-existing chronic conditions like a spinal tumor, multiple sclerosis, stroke, or long-standing diabetes can also damage nervous functioning, leading to accidental bowel leakage.
Damage to the surrounding nerves, the enteric nervous plexus (myenteric and Meissner’s plexus), along with the pudendal nerve and the parasympathetic nerves, decreases the rectal sensation and the muscle’s contractility. This loss of functions adversely affects the individual’s ability to defecate normally, resulting in fecal matter leaking involuntarily.
Impaired Stretch Capacity Of The Rectum
Normally, the rectum, like other parts of the intestines, can stretch, which helps retain the formed stool until it is time to defecate. However, this stretching ability can become impaired if the elasticity of the muscles is reduced.
The rectum’s elasticity can be reduced due to scarring or stiffening following conditions like irritable bowel syndrome, ulcerative colitis, Crohn’s disease, or radiation therapy or surgery complications.
This lack of elasticity reduces the rectum’s storage capacity, and it becomes unable to accommodate the excess volume of fecal matter being formed. As a result, the stool leaks out, causing fecal incontinence.
A few other etiologies of fecal incontinence include:
- Aging and subsequent weakening of the anal sphincter muscles, rectal muscles, and surrounding pelvic floor muscles.
- Impairment of cognitive ability as in Alzheimer’s disease, stroke, etc.
- Abuse of laxatives that make the stool loose.
- Congenital anorectal anomalies such as Hirschsprung disease, imperforate anus, and more.
- Presence of hemorrhoids that are dilated veins in the rectum. These swollen veins restrict the complete closure of the anal orifice, causing fecal matter to leak out.
Complications Of Fecal Incontinence: How It Impacts An Individual’s Well-Being
Fecal incontinence is a complex condition to manage and takes quite a lot of time to go back to normal or near normal. Complications usually arise as a result of mismanagement in the surgical route. On the other hand, the social stigma surrounding the issue of fecal incontinence also adversely impacts the affected individual’s overall quality of life. The various problems or complications fecal incontinence can cause for an individual includes:
Social And Emotional Distress
Having fecal incontinence can be embarrassing for an individual. Because of the stigma that revolves around this bowel issue can cause the person to withdraw from socializing with people, going out in public, and doing their daily activities or work. This causes them to develop social isolation, which negatively impacts their mental health. The affected person loses their self-esteem, starts to become angered or annoyed at every situation, and succumbs to depression and anxiety.
The frequent exposure to fecal matter, its contact with the surrounding skin, and constantly wiping it can cause the skin barrier around the anal orifice to become irritated. This irritated skin barrier can cause extreme discomfort with constant pain and itching. Moreover, the surrounding skin may even develop skin rashes, sores, ulcers, or in severe cases, skin infections if proper hygiene is not ensured.
Other than these complications, with recurrent irritation, the skin and subcutaneous tissue of the anal orifice might become separated. Additionally, the underlying blood vessels might undergo devascularization, which can lead to necrosis, and frequent bleeding and hematoma formation can also occur.
Risk Factors: Who Is More Prone To Developing Fecal Incontinence?
The chances of developing fecal incontinence, although it increases with age, is not the only factor. Various other risk factors also pose a higher risk for an individual to develop fecal incontinence. Some of the most common risk factors for fecal incontinence include:
Even though fecal incontinence can occur in an individual at any stage of life, it is more common in those aged 65 years or above. The reason behind this is simple. With advancing age, the anal sphincters, like other muscles, lose their tone. This results in an increased weakening of the involuntary control of the internal anal sphincter and the voluntary control of the external anal sphincter. Hence, older people are more prone to developing fecal incontinence.
Like urinary incontinence, fecal incontinence is more prevalent in women than in men. Being a female puts an individual at higher risk of developing fecal incontinence because of the physiological changes that take place throughout their life span. Vaginal or cesarean deliveries for childbirth or opting for hormone replacement therapy during menopause can become reasons for women to develop the problem of accidental bowel leakage.
Neurological Disorders And Nerve Damaging Conditions
Having a pre-existing neurological disorder like dementia, late-stage Alzheimer’s disease, or multiple sclerosis, can also make an individual prone to bowel incontinence. Furthermore, already existing pathologies or injuries that damage the nerves in the rectum increase the chances of precipitating accidental bowel leakage. A few of these high-risk conditions include long-standing and unmanaged diabetes and trauma to the back or spinal cord due to a surgical complication or external injury.
Disorders or injuries that limit an individual’s ability to move can also risk acquiring fecal incontinence. Any injury that is the primary cause of physical disability can damage the rectal nerves. Plus, the physical impairments may make it challenging for the affected individual to reach the bathroom in time, causing accidental leakage of the fecal matter.
Other than the ones mentioned, some other risk factors include:
- Being a smoker as, the tobacco content and other chemical irritants present in cigarettes weaken the pelvic floor muscles, and hence the muscles of the internal and external anal sphincters.
- Undergoing cholecystectomy or gall bladder removal. According to research, 20% of patients with gallbladder problems that undergo the surgical procedure for its removal develop recurrent diarrhea. The reason for this is that after the gallbladder’s removal, the direct delivery of excessive bile to the small intestines functions as a laxative. Hence, the collected fecal matter becomes loose and leaks out more rapidly.
- A physically inactive lifestyle can increase the risk of developing fecal incontinence as the anal sphincter muscles and other pelvic floor muscles become weak.
- Congenital malformations of the rectum, anus, or spinal cord are a primary risk factor for fecal incontinence in children.
Treating And Managing Fecal Incontinence
Fecal incontinence, when diagnosed early, is usually a treatable condition that can be cured completely by religiously following the prescribed treatment. After assessing the severity of your bowel condition, taking a detailed medical history, and diagnosing the underlying cause, your healthcare specialist would recommend a non-surgical or surgical treatment route.
In many instances, a combination of treatments is usually recommended to manage the symptoms and maintain a long-lasting normal bowel process. So, depending on the state of your fecal incontinence, the following treatments, and management techniques might be recommended:
The non-surgical management is recommended as the first line of treatment for controlling fecal incontinence. This initial management comprises dietary changes, physiotherapy, pharmacological management, and implants or external devices.
- Increased intake of dietary fiber to improve consistency and composition of the stool formed.
- Avoid consuming caffeine to prevent diarrhea.
- Refrain from alcohol consumption to prevent irritation of the gastrointestinal tract.
- Avoid intake of food items that can cause loose stools like spicy foods, beans, legumes, cabbage-family vegetables, cured meats, etc.
- Avoid consuming dietary items with a high level of fructose or lactose, such as dairy products, fruit juices, artificial sweeteners, etc.
- Consume stool-thickening foods like bananas, pasta, potatoes, etc.
- In order to prevent constipation and maintain hydration levels, drink several glasses of water per day.
Physical Training And Biofeedback Therapy
The physical therapies for treating fecal incontinence include exercise and training routines that aim to improve bowel control by strengthening the muscles involved in the defecation process. A commonly recommended routine for fecal incontinence is Kegel exercises, which are also effective for individuals with urinary incontinence. These exercises involve contracting the pelvic floor muscles, which help in strengthening their tone and reducing the frequency of bowel incontinence.
Another training usually recommended by healthcare specialists is bowel training. This technique involves creating a scheduled routine for bowel movements throughout the day. The affected individual can regain voluntary control over their bowel movements by setting up fixed times and intervals between toilet visits. Bowel training is an ideal initial physical therapy for improving the condition of urge fecal incontinence.
However, the healthcare professional might recommend biofeedback therapy if the affected individual cannot perform the exercises properly. This therapy is also recommended for patients with loss of rectal distension sensation and impaired tone of anal sphincter muscles. The therapist places a sensor on the abdominal wall or inside the anal orifice, providing feedback on which muscles are used while performing the exercises. This method can assist in improving the control of the bowel muscles.
The pharmacological route is recommended, usually in combination with dietary changes and physical training, and aims to reduce bowel movements’ frequency while improving the feces’ consistency. Following are some commonly prescribed pharmaceutical drugs for treating fecal incontinence:
- Methylcellulose functions as a bulking agent to improve the consistency of the fecal matter. It helps solid loose, watery feces, allowing the affected individual to hold in stool more effectively.
- Loperamide, commonly sold under the brand name Imodium, is effective in reducing stool frequency and improving bowel urgency. It also acts on the anal sphincter muscles, increasing their resting time and improving the transit time through the colon.
- Hyoscyamine, an anticholinergic medication, is recommended for patients who experience fecal incontinence right after consuming their meals. Its chemical composition acts on the colon, reducing its contraction and slowing down the elimination of feces.
- Co-Phenotrope, like Lomotil, a combination of atropine and diphenoxylate, is prescribed to patients whose fecal incontinence stems from an underlying cause of recurrent diarrhea. It works to reduce the frequency and number of bowel movements per day.
- Estrogen replacement therapy is also recommended for post-menopausal women who have low estrogen levels.
- Amitriptyline can also be prescribed if the individual has a cause of combined fecal and urinary incontinence.
Implants And External Devices
In some cases of fecal incontinence, smaller devices may be implanted near the rectal nerve region that produces minute electrical pulses for stimulating the anorectal muscles. This electrical stimulation improves the strength and control of the sphincter muscles, enhancing voluntary control over fecal movement.
Other devices like anal plugs can help in controlling the number of times you go to the toilet. These devices are removable but might cause slight discomfort.
Some newer non-surgical procedures for treating the condition of fecal incontinence include:
- Radiofrequency therapy or anal sphincter remodeling utilizes heat to make the anal sphincter muscles thicker.
- Injectable biomaterials for anal sphincters like dextranomer/hyaluronic acid, collagen, or silicon also improve their thickness.
Ensure skin hygiene is maintained with regular cleaning to prevent skin irritation and infections. Applying moisturizing creams and zinc oxide can also prevent skin irritations such as rashes. Moreover, using incontinence pads can prevent the risk of skin soiling.
The surgical route is recommended when fecal incontinence fails to respond to non-invasive management. If there is an underlying structural problem and bowel function is severely impaired, any of the following surgical procedures might be used:
- Sphincteroplasty, sphincter surgery, or overlapping sphincter repair stitches the damaged anal muscles tightly together. This procedure results in a more tightened anal opening.
- Sacral nerve stimulations through a neurotransmitter implant surgically placed under the upper gluteal region. It is effective for patients with fecal incontinence due to nerve damage and electrically stimulates the sacral nerve in the lower back.
- Insertion of an artificial bowel sphincter or a sphincter cuff device to control bowel movements if the normal function of the anal sphincters becomes impaired.
- Antegrade Continence Enema or ACE procedure creates a small channel from the abdomen to the bowel, and enema is given daily through the inserted tube to remove stool.
- A colostomy is usually the last resort when other surgical procedures fail to show results. It involves bringing the colon to the skin surface from where the fecal matter is collected in an external pouch.
Fecal incontinence can be an upsetting condition for anyone suffering from it. Although the stigma surrounding it might cause you to hesitate to seek help, getting it assessed early can assist in quick and better recovery. If you observe any of the symptoms mentioned above, consult a trusted healthcare specialist to receive an early diagnosis for the underlying cause and effective treatment for improving your bowel control.