Fecal incontinence, also called a bowel control problem, is the accidental passing of solid or liquid stool or mucus from the rectum. Fecal incontinence includes the inability to hold a bowel movement until reaching a toilet as well as passing stool into one’s underwear without being aware of it happening.
Stool, also called feces, is solid waste that is passed as a bowel movement and includes undigested food, bacteria, mucus, and dead cells. Mucus is a clear liquid that coats and protects tissues in the digestive system.
Fecal incontinence can be upsetting and embarrassing. Many people with fecal incontinence feel ashamed and try to hide the problem.
However, people with fecal incontinence should not be afraid or embarrassed to talk with their health care provider. Fecal incontinence is often caused by a medical problem and treatment is available.
What causes bowel incontinence?
Fecal incontinence occurs because of an underlying disease or illness (it is not considered a “disease”). There are numerous potential causes and many patients have more than one reason to cause loss of bowel control.
Damage to muscles and nerves may occur directly at the time of vaginal childbirth or after anal or rectal surgery.
Neurologic diseases such as stroke, multiple sclerosis, spinal cord injury, and spina bifida can be potential causes of fecal incontinence. Complications of diabetes can also cause peripheral nerve damage leading to incontinence.
Patients with inflammatory bowel disease (Crohn’s disease, ulcerative colitis) and irritable bowel disease may develop fecal incontinence.
Stool seepage is different than fecal incontinence. Minor staining can occur in people who have hemorrhoids, rectal fistula, rectal prolapse and poor hygiene.
Other causes include chronic diarrhea, parasite infections, and laxative abuse.
Paradoxical diarrhea or overflow incontinence may occur is a a person who has chronic constipation. In paradoxical diarrhea, stool fills the rectum, hardens and becomes impacted.
Liquid stool leaks around the fecal mass, imitating incontinence.
Who gets fecal incontinence?
Nearly 18 million U.S. adults—about one in 12—have fecal incontinence.1 People of any age can have a bowel control problem, though fecal incontinence is more common in older adults.
Fecal incontinence is slightly more common among women. Having any of the following can increase the risk:
- diarrhea, which is passing loose, watery stools three or more times a day
- urgency, or the sensation of having very little time to get to the toilet for a bowel movement
- a disease or injury that damages the nervous system
- poor overall health from multiple chronic, or long lasting, illnesses
- a difficult childbirth with injuries to the pelvic floor—the muscles, ligaments, and tissues that support the uterus, vagina, bladder, and rectum.
What are the symptoms of bowel incontinence?
Bowel incontinence refers to the inability to control the passage of small amount of stool, liquid or solid, or control flatus.
People are sometimes reluctant to discuss their lack of bowel control because of the social stigma attached to it. Their initial complaint might be anal itching (pruritis ani), a buttock skin infection, or breakdown of the skin and ulcers.
How is fecal incontinence diagnosed?
Health care providers diagnose fecal incontinence based on a person’s medical history, physical exam, and medical test results. In addition to a general medical history, the health care provider may ask the following questions:
- When did fecal incontinence start?
- How often does fecal incontinence occur?
- How much stool leaks? Does the stool just streak the underwear? Does just a little bit of solid or liquid stool leak out or does complete loss of bowel control occur?
- Does fecal incontinence involve a strong urge to have a bowel movement or does it happen without warning?
- For people with hemorrhoids, do hemorrhoids bulge through the anus? Do the hemorrhoids pull back in by themselves, or do they have to be pushed in with a finger?
- How does fecal incontinence affect daily life?
- Is fecal incontinence worse after eating? Do certain foods seem to make fecal incontinence worse?
- Can passing gas be controlled?
People may want to keep a stool diary for several weeks before their appointment so they can answer these questions. A stool diary is a chart for recording daily bowel movement details.
How is bowel incontinence diagnosed?
Taking a history is very important and the health care professional will spend time learning about how often loss of bowel control occurs, in what situations and whether it is solid, liquid, or gas.
Past medical and surgical history is important, especially obstetric history or surgery of the anus, including hemorrhoids.
It could be several years before the complication of a surgery or childbirth lead to fecal incontinence. Dietary habits and medications (including over-the-counter medications and laxative) will also be considered and evaluated.
Physical examination will likely include a rectal examination to assess sphincter tone. In females, a pelvic exam will also be performed.
While blood tests are not usually needed to make the diagnosis, other tests may be helpful in deciding the potential cause of fecal incontinence.
Anal manometry measures the pressure within the rectum, both at rest and when the patient squeezes the anal sphincter.
Nerve and muscle conduction studies may be considered. Ultrasound can evaluate the anal sphincters and look for muscle damage.
What is the treatment for bowel incontinence?
The treatment approach for a patient with fecal incontinence is individualized based upon the underlying cause.
The purpose is to regulate bowel movements, decrease their frequency, and increase stool firmness and consistency. Often this involves dietary changes and the use of medications that bulk the stool.
Increasing the strength of the muscles of the pelvic floor might be helpful. Kegel exercises and electrical stimulation may be recommended.
Biofeedback is often used to help retrain the anal sphincters and have the patient appreciate the sensation of rectal fullness that comes just before the need to defecate.
If the incontinence persists even after maximum medical therapy has been attempted, surgery may be an alternative.
If damaged, attempts can be made to repair the muscles of the pelvic floor including the external anal sphincter. The internal anal sphincter function may be enhanced by injecting materials like silicone, carbon beads, or collagen.
As a last resort, where all other options have failed, a colostomy may be performed, where the colon is diverted through the abdominal wall to empty into a removable bag.