Gastrointestinal problems can tend to be a taboo subject for most people, especially when it comes to conditions related to feces and defecation. Humans are just generally uncomfortable with those aspects of how the body functions, and this can include adults as well as children. In fact, some children get so uncomfortable with the psychological elements of defecation that they force themselves to “hold it in” so long that it becomes harmful. Perhaps one of the most challenging examples of a gastrointestinal problem that can affect people of all ages: fecal incontinence.
What is Fecal Incontinence?
Simply put, fecal incontinence is a temporary or permanent inability to control defecation, the final step of the digestion process where feces are eliminated via the anus. Bladder and bowel control are normally learned within the first 2-3 years after being born, but a variety of factors can lead to the loss of that ability later in life. This condition is relatively common; according to the American College of Gastroenterology, approximately 5.5 million Americans have fecal incontinence, and it tends to be more common in women and older people. However, because of the taboo nature of the condition, it is possible that there are more people who have it but who haven’t reported it.
Under normal circumstances, continence (the ability to effectively control defecation) relies on several different interrelated body systems as well as both conscious and unconscious activation of muscles. The primary mechanism is called the rectoanal inhibitory reflex (RAIR), and it involves the involuntary relaxation of anal sphincter muscles that is triggered when the rectum (the final segment of the large intestine) is full and distended. In addition to signalling the conscious mind that it’s “time to go,” this reflex also enables us to differentiate in the upper anal canal between feces and flatus (gas).
This process is able to function normally because of the interplay between the external anal sphincter, internal anal sphincter, rectum, anus, pelvic floor muscles, and enteric nervous system. All these components work together so that a person can sense when stool is in the rectum (rectal sensation) and potentially hold it there until a convenient time (this is called rectal compliance). In someone with rectal incontinence, though, one or more of those components are functioning abnormally and stool is then passed involuntarily; this can range from minor leakage to total loss of control.
What Are the Causes of Fecal Incontinence?
Fecal incontinence is a symptom of an underlying condition rather than a primary condition, so there are a variety of potential causes. Damage to or malfunction of any one of the components of defecation can result in some form of fecal incontinence. Below are some of the most common causes:
- Childbirth: As noted earlier, women are more likely than men to develop fecal incontinence, in part because of the physical stress of vaginal delivery during childbirth. Birthing a particularly large baby, the doctor’s use of forceps, and the need for an episiotomy are all factors that can potentially damage the muscles of the pelvic floor or the anal canal and make fecal incontience more likely.
- Muscle damage: When any of the muscles involved in defecation are weakened or damaged, fecal incontinence can result. These muscles can be weakened through a reaction to certain types of surgery, childbirth, excessive straining during defecation, or through some sort of trauma.
- Nerve damage: Damage to the nerves in the vicinity of the anus (part of the enteric nervous system) can be related to the same causes as muscle damage, but it can also be a result of nerve damage related to a spinal cord injury or even a stroke.
- Constipation: Chronic constipation is a long term bowel irregularity problem that can cause you to frequently attempt to pass hard, dry stools; over time, excessive straining to pass these stools can lead to a weakening of the sphincter muscles on either side of the anal canal. Severe constipation can even lead to impacted stools that can’t be passed without therapeutic intervention; in such cases, softer, watery stools may leak out around the impacted stool.
- Diarrhea: The watery, loose stools associated with diarrhea are more difficult to hold in the rectum than solid stools. Chronic diarrhea, particularly when combined with other factors like sphincter muscle weakness, can lead to fecal incontinence simply because the muscles aren’t strong enough to constantly maintain the urge to hold it in. This type of incontinence may only result in isolated incidences of not being able to hold it.
- Hemorrhoids: Hemorrhoids are swollen or inflamed blood vessels located in and around the anus and anal canal. In addition to being a painful annoyance in themselves, hemorrhoids can swell to such a degree that the anus won’t close properly. Though it isn’t usually associated with full loss of bowel control, it may cause minor leakage of more liquid stool.
- Surgery: There are many types of surgery (including surgery to treat colorectal cancer) focused on the lower gastrointestinal tract that can potentially cause damage to the muscles involved in defecation. Some hemorrhoid treatment procedures can also potentially cause problems with incontinence, though they’re usually temporary.
- Rectal prolapse: Though relatively rare, it is possible for the rectum to become prolapsed; this means that the rectum is pushed out into the anal canal and causes the anal sphincter muscles to be stretched. Even if and when the prolapse is resolved, the nerve damage to the muscles can lead to some amount of fecal incontinence.
- Neurological disease: Similar to general nerve damage, some neurological conditions like multiple sclerosis, Parkinson’s disease, and even dementia can cause fecal incontinence because of the impact of those diseases on the neurological health of the digestive system and the body as a whole.
- Physical inactivity: A common concern among older adults and those in nursing homes, physical inactivity can contribute to constipation and then ultimately some form of fecal incontinence. Even outside of nursing homes, an extreme lack of physical activity—especially when combined with other factors listed here—can make someone more susceptible to fecal incontinence.
Diagnosis and Treatment of Bowel Incontinence
Because fecal incontinence can be caused by so many different factors, diagnosing the underlying condition can be somewhat elusive. It is complicated by the fact that related gastrointestinal symptoms like diarrhea and constipation can also be symptomatic of a variety of other conditions. One useful tool gastroenterologists sometimes use in such diagnoses is called anorectal manometry. This test involves the insertion of a small catheter into the anus to test the strength of the sphincter muscles. The data received from the test can help the doctor determine the cause of fecal incontinence and whether or not it is related to a muscle problem. The doctor may also use X-rays, magnetic resonance imaging (MRI), or the flexible tube of a colonoscopy to help diagnose for a visual examination of the area.
Depending on the underlying cause, medication, therapeutic exercises, or surgery may be used to treat or manage incontinence. Over-the-counter medications like laxatives or loperamide (Imodium) are usually limited to ameliorating diarrhea or constipation, and there aren’t really any medicinal options for other causes. Instead, the gastroenterologist may utilize different therapeutic options:
- bowel training: training yourself to have bowel movements at certain times of day (such as after a meal)
- Kegel exercises: tightening and relaxing the pelvic floor muscles repeatedly throughout the day can help the patient relearn bowel control
- biofeedback: sensor technology is used to help strengthen related muscles through real time feedback
- colostomy: in more severe cases, colostomy surgery is used to create an opening to the colon through the abdominal wall and a specialized bag collects stool
- sacral nerve stimulation: electrical stimulation of the sacral nerves under the tailbone can help the nerves involved in defecation function properly
- dietary changes: in some cases, modifying one’s diet or introducing fiber supplements can reduce the likelihood of diarrhea and constipation and, in turn, fecal incontinence
At Cary Gastroenterology Associates, we are a healthcare provider that understands how sensitive and challenging it can be to struggle with a problem like fecal incontinence. That is why our highly qualified doctors and staff are dedicated to providing excellent healthcare with compassion and discretion so that you can improve your quality of life. If you have been experiencing a form of fecal incontinence, we are here to help. Please contact us to request an appointment to speak with a gastroenterologist.