Bowel incontinence

Bowel incontinence - What is bowel incontinence?

Bowel incontinence or fecal incontinence is a condition that is a primarily associated with an inability to control bowel movements. This means that the patient is unable to hold stools that leak uncontrollably from the rectum via the anus.

The stool movement is a complex process which integrates the rectal muscles and the internal and external anal sphincter complex along with pelvic floor muscles and nerve complexes around the area.

The nerve complexes are situated in the wall of the rectum, pelvic floor and lining of the anal canal. These send signals to the brain for deferring defecation until social conditions are suitable. 1-6

Causes of bowel incontinence

Bowel incontinence is not a condition in itself but a symptom of an underlying problem or medical condition that could be due to damage to a muscle or a nerve that controls the sphincter (anal sphincter) that controls bowel evacuation.

It can affect people of any age but is most common among the elderly who have weakened muscles and nerves around their rectum and as a complication of pregnancy. In this way this condition is slightly more common in women than men.

Risk factors of bowel incontinence

Risk factors include:

  • patients with diarrhoea

  • women who have had severe (third- and fourth-degree) injury to their pelvic muscles while giving birth vaginally

  • those with rectal prolapse or pelvic organ prolapse due to weak pelvic floor muscles

  • those who have undergone radiation therapy or colon surgery due to cancers

  • those with urine incontinence

  • frail elderly patients

  • those with dementia and severe cognitive impairment or learning difficulties

  • those with nerve damage like spinal injury, spina bifida, multiple sclerosis etc.

Epidemiology of bowel incontinence

Around 2.2% of the population is diagnosed with bowel incontinence. However, the actual figures may be higher as many patients do not seek therapy for the embarrassment caused by the condition.

In people over 65 living in care facilities, the prevalence of the condition is as high as 7%. More than 5.5 million Americans have fecal incontinence and some studies believe that as many as 25% of the population that is institutionalized may have some symptoms of fecal incontinence.

Symptoms of bowel incontinence

The severity varies from individuals and for some it may be passing just a small piece of stool when passing wind and in some it may be complete evacuation of stool. There is a severe impact of this condition on the quality of life, self-esteem and emotional wellbeing of the sufferer.

It hampers social life to a great extent as well and may lead to other mental health conditions like depression and anxiety disorders. Bowel incontinence is much more common than most people realise as many patients are unwilling to come forth with their condition until it worsens.

Diagnosis of bowel incontinence

Many people with bowel incontinence do not seek medical treatment for their condition until it is too late. Bowel incontinence will not always go away without treatment and is not a normal part of aging or pregnancy after-complication.

Diagnosis is made by physical examination or digital rectal examination that helps in assessing the sphincter function.

Other tests include:

  • Endoscopy

  • anal manometry

  • anal electromyography

  • defecography to test the nerve and muscle functions of the rectum and pelvic floor muscles

Treatment of bowel incontinence

There are a range of medical and surgical therapies available for bowel incontinence that may treat the condition successfully. With the right therapy at the right time a person can maintain normal bowel function throughout their life.

Treatment options include changes in lifestyle, bowel habits and diet as well as exercise programmes. Medications and surgery is also undertaken as part of therapy.

Causes of bowel incontinence

Bowel movements are regulated by the muscles and nerves around the rectum, anus, sphincters (internal and external) as well as the pelvic floor muscles. The common factors that affect the normal bowel function leading to incontinence include:

  • inability of the rectum to hold the stool until social conditions permit evacuation

  • inability of the sphincters and muscles to hold the stool till appropriate time

  • damage to the nerves that send signals from the rectum to the brain normally allowing control of the bowel motions

Rectal muscles problems include:

  • constipation

  • diarrhea

  • rectal cancer

Sphincters may be damaged due to injury during childbirth or due to other injuries. Nerve damage may occur due to spinal injuries, multiple sclerosis, spina bifida etc. 1-7

How does bowel incontinence occur?

There are two sets of sphincters or gates that control the stool movements in the rectum. If there is a problem or injury to the internal sphincter it may open automatically to let stools pass into the rectum. This causes the rectum to fill up and in turn leads to nerves of the rectal wall being stimulated leading to the brain giving signals for evacuation of bowel contents.

The external sphincter in these cases controls the bowel motions and prevents incontinence. In case of injury to the external sphincter as is common after a difficult vagina child birth, there may be leakage of stool and this leads to bowel incontinence in the long term. Vaginal delivery may lead to excessive stretching of the sphincter muscles and damage them. Forceps or assisted deliveries are also implicated.

Bowel or rectal surgery, fistula or fissure surgery, hemorrhoidectomy or piles surgery, manual dilatation of the sphincters, impaled injury to the anus and rectum are other causes of sphincter injury and damage.

Causes of bowel incontinence

Causes of bowel incontinence thus includes diarrhea, severe constipation and so forth.

Diarrhea and bowel incontinence

In diarrhea the rectum is unable to hold the stool as it has large amounts of water in it. Those with conditions that lead to diarrhea like irritable bowel syndrome (IBS), Crohn’s disease or ulcerative colitis that lead to inflammation of the digestive system and the large bowel may also have diarrhea leading to bowel incontinence.

Inflammatory conditions also lead to rectal scarring and bowel incontinence.

Severe constipation and bowel incontinence

Severe constipation may lead to hard and large quantities of stool to be stuck in the rectum. This is called faecal impaction.

The stool then begins to stretch the muscles of the rectum and makes them weak. This leads to incontinence of the bowel.

Rectum cancer and bowel incontinence

Rectum cancer or tumors also make the rectal muscles weak and may lead to bowel incontinence.

Nerve damage of bowel incontinence

Nerve damage may lead to bowel incontinence. Muscle and nerve damage is common among frail elderly individuals. Other conditions that predispose to nerve damage include:

  • diabetes mellitus

  • multiple sclerosis

  • spina bifida (a congenital birth defect of the spine)

  • after a stroke

  • spinal injury etc.

Nerve and muscle damage may also be seen after radiation therapy or colon surgery for colon or rectum cancer. Those with urinary incontinence are at a high risk of bowel incontinence as well. This could be associated with the nerves around the pelvic muscles.

Severe cognitive loss and bowel incontinence

Bowel control may also be lost in individuals with severe cognitive loss and dementia. This includes those with learning disabilities, Alzheimer’s disease etc.

Other causes of bowel incontinence

Poor overall health, severe malnutrition, multiple chronic, or long-lasting, illnesses may also lead to bowel incontinence.

Symptoms of bowel incontinence

How many people does bowel incontinence affect?

Bowel incontinence or fecal incontinence affects around 2% of the general population and may affect up to 25 to 50% of the institutionalized population of patients.

The general prevalence of 2 to 7% in the population is considered a gross underestimate since many patients do not come forth to the health care providers with their condition due to embarrassment.

How does bowel incontinence affect quality of life?

Bowel incontinence leads to a severe impact on the quality of life, emotional and physical wellbeing of the patient. The social, personal life as well as hygiene is severely affected. The symptoms are widely varied among individuals and no two persons have similar symptoms.

Bowel incontinence in women

Women are commonly affected with bowel incontinence especially after giving birth vaginally. Pregnancy and childbirth leads to stretching of the pelvic floor muscles and rectal sphincters raising the risk of bowel incontinence.

Menopause, removal of uterus surgeries as well as other gynecologic surgeries in women also raises the risk of bowel incontinence.

Among the elderly up to 20% of women and 10% of men live with bowel incontinence. In nursing homes, rates of bowel incontinence may be as high as 50%.

How often does bowel incontinence occur?

Bowel incontinence may be experienced daily, weekly or monthly and may be associated with certain stressful conditions or episodes of constipation or diarrhea alone with no symptoms in between episodes.

Bowel incontinence is usually a symptom of an underlying condition affecting the nerves and muscles of the rectum, anal canal and the pelvic floor rather than a disease in itself.

Symptoms of bowel incontinence include: 1-6

  • Mild incontinence like passage of small bits or amounts of stool while passing wind or straining (like lifting weights etc.). Some may pass a small piece of stool while passing wind and this may be liquid or solid stools.

  • Sudden urge to go to the toilet and mild incontinence because the patient is unable to reach a toilet in time. This is known as urge bowel incontinence. This is common among the elderly.

  • Passive soiling occurs in some patients when they have no sensation while their bowels are evacuated uncontrollably. This is called passive incontinence

  • There may be stool leakage in some individuals that is a continuous small amount of stool leaking out of the anus.

  • Urinary incontinence or inability to control the leakage or flow of urine is a commonly associated symptom with bowel incontinence.

  • There may be associated diarrhea or constipation.

  • There may be itchiness, soreness or pain around the anus and the skin around the anus.

  • Abdominal pain and cramps may be seen in some individuals.

  • There may be bloating of the abdomen and other symptoms of abdominal discomfort.

Diagnosis of bowel incontinence

Diagnosis of bowel incontinence or fecal incontinence depends of various factors. History of childbirth, age, sex and history of a rectal or anal surgery are important predictors of diagnosis and outcome of the condition.

The diagnosis of bowel incontinence includes detailed analysis of symptoms, digital rectal examination and so forth.1-5

Detailed analysis of symptoms of bowel incontinence

Detailed analysis of symptoms of the incontinence. The bowel incontinence may be one of the three classical types –

  • Urge incontinence – the patient is unable to hold the stools after the urge or need to evacuate arises and needs to visit the toilet immediately
  • Passive incontinence – the person has no sensation of a complete bowel evacuation. There is not urge or feeling of need to evacuate the bowels whatsoever.
  • Leakage of stools – there is a constant leakage of stools.

Other questions include patterns of diet, and episodes of constipation, diarrhea and other abdominal symptoms.

History of difficult vaginal; childbirth, age of the patient, cognitive status or dementia and other mental health conditions need to be assessed during evaluation of a case of bowel incontinence.

All risk factors affecting rectal, anal and pelvic muscles, sphincters of the rectum and anus as well as nerve damage are thus, fully evaluated.

Digital rectal examination

A digital rectal examination is then performed. This involves insertion of a lubricated gloved finger into the anus gently to assess the insides of the rectal wall and the sphincter functions.

A local anesthetic gel is usually used and the condition is usually not severely painful.

Endoscopy of the rectum

An endoscopy of the rectum or Proctosigmoidoscopy may be prescribed. A thin long tube with a light and camera on its tip is inserted into the rectum and the inner walls are viewed for any abnormalities.

This is usually not painful but may be uncomfortable and many patients are sedated for the procedure.

The inner walls of the rectum may be visualized using a proctoscope as well.

Anal manometry

Anal manometry is another test that is recommended. This is a small device like a thermometer with a balloon attached to the end. The device is inserted into the rectum and the balloon is inflated. This is usually not painful or uncomfortable.

A machine is attached to the device. This machine reads the pressure readings taken from the balloon. Manometry is performed to assess the strength of the sphincter muscles, rectal muscles and the nerve functions of the rectum.

In addition, the balloon may be inflated to different sizes to determine when the rectum feels full. If the balloon is relatively large and still no sensation of fullness appears there may be a problem with the rectal nerve complexes.

Ultrasound for diagnosis of bowel incontinence

Ultrasound is sometimes prescribed to assess the rectum as well as abdominal pathologies that may be leading to bowel incontinence.

Defecography

Defecography or Proctography may also be recommended. This test involves drinking a harmless liquid called barium. Barium is used because it is visible on X-rays. Patient is asked to pass stool while X rays are taken. This reveals fecal impaction and obstructions in stool passage.

Anal electromyography

Anal electromyography is yet another test that checks for any damage to the nerves of the rectum that pass the message of fullness to the brain.

In this test small electrodes are inserted in the muscles around the anus. These detect the electrical signals from the rectal and anal muscles that are transmitted through the nerves to the brain.

Magnetic resonance imaging (MRI)

Magnetic resonance imaging (MRI) shows the detailed picture of the rectum and the sphincters and may be prescribed.

Treatment of bowel incontinence

Bowel incontinence or fecal incontinence is a treatable condition. It affects 2 to 7% of the general population and nearly 25% of the institutionalized population.

Most patients are women usually due to injury to the pelvic floor muscles and the anal sphincters after a complicated vaginal childbirth or frail elderly men with weakened muscles of the rectum and damaged nerve complexes.

The actual prevalence of the condition is far more than the known figures since many patients with this embarrassing condition do not contact their healthcare provider.

Further, bowel incontinence is a symptom of an underlying condition rather than a disease in itself. It is essential that the condition is detected early and treated to prevent further complications.

The treatment plan also depends on the underlying cause of the condition and the pattern of the symptoms. According to the general principles of therapy, the physicians try the least intrusive treatments first before more invasive methods.

The first steps include dietary changes and exercise programmes. More invasive methods include medication or surgery and are considered only if other treatment options are unsuccessful.

Treatment includes the following methods: continence products, diet modification, medicines and so forth. 1-7 –

Continence products

These include anal plugs that are a good way to prevent episodes of soiling. The plugs are made of foam and designed to be inserted into the anus. Since the plug is made of foam it expands like a mushroom when it comes in contact with any moisture from the bowel. This prevents any further leakage.

These can be worn for up to 12 hours and may be removed by pulling the attached string. It may feel uncomfortable initially but the symptoms usually resolve with time.

Another option is an adult diaper or a disposable pad. These soak the liquid stools and protect the skin. These are useful in mild bowel incontinence.

Diet modification for bowel incontinence

When bowel incontinence is associated with diarrhoea or constipation, the symptoms may be reduced using changes in diet. Those with soft or loose stools may be given a low fibre diet.

Patients with constipation need high fibre in diet to soften and produce formed stools. Patients are asked to maintain a food diary to record the effect of the dietary changes on the symptoms of incontinence.

Patients with diarrhea associated with bowel incontinence are advised to take reduced insoluble fibre in diet. Insoluble fibre sources in diet include wholegrain breads, bran, cereals and nuts.

Patients are advised to avoid fibre from fruits and raw vegetables as well and limit foods with resistant starch such as pulses, whole grains, corn and green bananas. Foods with high fat content also need to be avoided.

Patients who have predominant constipation need high-fibre diet. These include fruits, vegetables, beans, whole grains, seeds, nuts, oats etc. These patients are also advised to drink plenty of water to soften the stools.

Medicines for bowel incontinence

Some medications, like Loperamide, may be used to treat diarrhea. This slows down the movement of the stools and may be needed for long periods of time in patients with diarrhea.

Laxatives may be prescribed to treat constipation in patients with bowel incontinence. Bulk-forming laxatives are usually recommended.

Exercise programmes for bowel incontinence

Patients of bowel incontinence may need pelvic floor muscle training. These are important for all women after vaginal childbirth. These exercises strengthen any muscles that may have been stretched and weakened during childbirth.

These exercises are needed at least exercises three times a day, for six to eight weeks after delivery. The basic tenet of these exercises includes squeezing and holding the pelvic muscles in the taut position while sitting, standing or lying positions.

The breath is held while the muscles are held tight and then again let off as the muscles are relaxed.

Bowel training

This is recommended for people who have reduced sensation in their rectum as a result of nerve damage. These include:

  • establishing a regular time for bowel evacuation

  • making the constituency of the stools amenable for easy evacuation

  • stimulating the bowel for movement

Stool consistence may be improved by dietary modification. A time is set aside in the daily routine for bowel evacuation. Sometimes a hot drink or a meal may help in bowel evacuation stimulation.

Biofeedback method for bowel incontinence

This is a method of bowel retraining that uses a small electric probe within the anus. This probe sends back information about the movement and pressure of the muscles in the rectum to a computer. Exercise programmes are then prescribed to improve the bowel function.

Enemas for bowel incontinence

Some patients may also benefit from enemas. This is useful in patients with faecal impaction. The enema involves insertion of a small tube in the anus and irrigation of the rectum with a special solution to wash the walls out.

Surgery for bowel incontinence

Surgery for bowel incontinence is the last resort and is needed only in very severe cases.

Open surgeries like sphincteroplasty may be undertaken to correct the torn or damaged sphincter muscles. In this surgery the muscle edges are overlapped and sewn back together to make the sphincter stronger.

Some patients may require replacement of the sphincter muscles called stimulated graciloplasty. The sphincter is created using a sample of muscle from the thigh of the patient.

Endoscopic heat therapy is tried in some patients. This technique uses heat via a thin probe over the sphincter muscles to encourage scarring of the tissue and tighten the sphincter.

Bulking agents like collagen or silicone can be injected into the muscles of the sphincter and rectum to strengthen them. Sacral nerve stimulation and tibial nerve stimulation may also be undertaken in patients with weak sphincter muscles.

Some patients may need a radical surgery called the colostomy. In this the lower bowel or colon is cut and brought out through the wall of the abdomen after creating an opening and a bag, known as a colostomy bag is attached to the opening to collect the stool.

Psychological support for bowel incontinence

Emotional and psychological support to the patient and family is important and assessment and treatment of depression and other mental health conditions play a vital role in therapy.

Those with cognitive impairment need behavioural and functional analysis and cause-specific behavioural interventions may be tried.

Maintaining hygiene

Patients also require skin care, odour control, disposable gloves and other laundry advice to maintain hygiene.