What is Faecal Incontinence?
Faecal (or Fecal) incontinence is an inability to control bowel movements, resulting in the involuntary passage of stools. It is also sometimes known as bowel incontinence.
The experience of faecal incontinence can vary from person to person. Some people feel a sudden, urgent need to go to the toilet, and incontinence occurs because they are unable to reach a toilet in time (similar to urge urinary incontinence). This is known as urge faecal incontinence.
Others may experience no sensation at all before passing a stool, this is known as passive incontinence or passive soiling. Alternatively they may pass a small piece of stool while passing wind. Some people experience faecal incontinence on a daily basis, whereas for others problems only occur from time to time.
How common is Faecal Incontinence?
Faecal incontinence (sometimes spelt as Fecal Incontinence) is more common than many realise. It is thought around 10% of people will be affected by it during their lives. It can affect people of any age, though the problem is more common in elderly people. Recent studied from the UK primary care database showed the condition was more common for women. People with the highest likelihood of developing faecal incontinence are patients with anal problems (such as women with third or fourth-degree obstetric injury, people with rectal or pelvic organ prolapse, those undergoing pelvic radiotherapy or colonic resection and patients with perianal itching, soreness or pain or anal surgery), people who experience with urinary incontinence, the frail or elderly, people with dementia, neurological problems or spinal disease (eg, CVE, MS, spina bifida or spinal injury) and those with severe cognitive impairment or learning difficulties.
What Causes Faecal Incontinence?
Faecal incontinence is not a condition in itself. It is a symptom of an underlying problem and conditions making it important to seek medical assessment to treat the underlying cause.
There are potential causes, some more common than others, usually triggered by a physical issue with parts of the body controlling passage of stools.
The most common cause is damage to one or both of the anal sphincter muscles. The external anal sphincter is responsible for delaying bowel emptying once the rectum fills and the urge to empty the bowel is felt. People with a weak or damaged external anal sphincter muscle typically experience urgency and may pass stools before they are able to reach a toilet. People with a damaged internal anal sphincter usually experience 'passive soiling', where soft or small pellets of stool leak out without realisation.
Constipation is a leading cause of bowel incontinence. In cases of severe constipation, a large, solid stool can become stuck in the rectum, known as faecal impaction. This begins to stretch and weaken rectum muscles. Watery stools can leak around the stool bottom, causing faecal incontinence.
Diarrhoea can be a cause as well as symptom. Diarrhoea can be chronic, i.e. on-going and reoccurring, or acute, i.e. sudden and unexpected.
Conditions that can cause recurring diarrhoea include Crohn's disease (causing inflammation of the digestive system), Irritable Bowel Syndrome (widely referred to as IBS, causing a range of digestive symptoms, including diarrhoea and bloating) and Ulcerative Colitis (a condition causing inflammation of the large bowel). All these conditions can cause scarring of the rectum, which can lead to faecal incontinence.
Faecal incontinence is also caused by problems with the nerves connecting the brain and the rectum. A nerve problem can mean your body is unaware of stools in your rectum, and may make it difficult to control your sphincter muscles. Nerve damage can be related to a wide number of conditions, including diabetes, multiple sclerosis, stroke, spina bifida and spinal cord injury.
People with disorders like Parkinson's and Alzheimer's/Dementia can sometimes develop faecal incontinence associated with their illness. Some may develop incontinence following gynaecological, prostate or rectal surgery, as can chronic laxative abuse in the long term.
Some medications like antibiotics can cause loose stools / diarrhoea, worsening symptoms.
Diagnosing Faecal Incontinence
Faecal incontinence is a symptom, and there are often multiple contributory factors. Health professionals shouldn't concentrate on one diagnosis to the exclusion of other factors.
Before you see your health professional, keep a bowel diary for a week or so before your appointment to record trips to the toilet, any accidents you have and what you eat or drink. This will be useful for the Doctor, potentially highlighting underlying causes of your symptoms.
The starting point of diagnosis is baseline assessment including medical history, general examination, anorectal examination and assessment of cognitive function (if appropriate), identifying contributory factors before treatment is considered.
People with the following conditions should have these addressed with condition-specific interventions before healthcare professionals progress to initial management of faecal incontinence: faecal loading, causes of diarrhoea (for instance, infective, inflammatory bowel disease and irritable bowel syndrome), warning signs for lower gastrointestinal cancer, rectal prolapse or third-degree haemorrhoids, acute anal sphincter injury (including obstetric and other trauma) and acute disc prolapse/cauda equina syndrome.
Further tests that may be carried out include:
- Endoscopy - Internal examination of the rectum (and sometimes lower bowel) using a long, thin flexible tube with light and video camera attached. Images taken of the inside of your body are sent to an external monitor. This checks for obstruction, damage or inflammation in your rectum.
- Anal manometry - a device similar to a small thermometer with a balloon attached assesses how well the muscles and nerves in the rectum are working, and the level of sensation within those nerves.
- Ultrasound - Creates a detailed picture of the inside of your anus. Particularly useful in detecting underlying damage to the sphincter muscles
- Defecography - a test using liquid barium to study exactly how you are passing stools. Also useful in detecting signs of obstruction or prolapse not discovered from rectal examination.
How can I manage Faecal Incontinence?
With the right treatment many individuals can maintain normal bowel function throughout their life. Treatment often depends on the cause and severity of the condition, with a number of possible options.
Lifestyle and dietary changes can help relieve constipation or diarrhoea. It's important that nutrient intake remains balanced, and is advisable to modify only one food at a time. Those with hard stools or dehydration are encouraged to intake at least 1.5 litres of fluid per day (unless otherwise advised). Other advice includes limit fibre intake from wholegrain breads, bran, cereals, nuts and seeds (except golden linseeds), avoiding skin, pips and pith from fruit and vegetables, limiting fresh and dried fruit to three portions a day and fruit juice to one small glass a day (the remaining five a day can be achieved with vegetables), avoiding fizzy drinks, caffeine and high-fat foods, such as chips, takeaway and burgers.
A high-fibre diet is often recommended for constipation-associated incontinence, however it's important to discuss this with your Health professional who can confirm this course of action. Fibre can soften stools, making them easier to pass. High-fibre foods include fruit, vegetables, beans, wholegrain rice, wholewheat pasta, wholemeal bread, seeds, nuts and oats. Drinking plenty of fluids can also help with softening and passing stools.
Other causes of faecal incontinence may require more intensive interventions. If caused by weakness in the pelvic floor muscles then Pelvic floor muscle training is usually advised. The aim being to strengthen any stretched and weakened muscles. A therapist, usually a physiotherapist or specialist nurse, will teach you appropriate exercises. Ideally these should be carried out three times daily, for six to eight weeks, After this an improvement in your symptoms should be noticeable.
Bowel retraining assists those with reduced rectum sensation resulting from nerve damage, or those with recurring episodes of constipation. The three main goals of bowel retraining are improving stool consistency, establishing regular times to empty the bowels and finding ways of stimulating the bowels to empty themselves. Methods of stimulation differ from person to person. Some find a hot drink and meal can help, others may stimulate their anus using their finger.
Other treatments to consider include:
- Biofeedback - A bowel retraining exercise, placing a small electric probe into your bottom.
- Medication – Used to treat soft or loose stools or constipation associated with bowel incontinence. Common medications include Loperamide, treating diarrhoea by slowing down stool movement through the digestive system, allowing more water to be absorbed . Laxatives can treat constipation, helping passage of stools. Bulk-forming laxatives are usually recommended. These help stools to retain fluid, becoming less likely to dry out and cause faecal impaction.
- Enemas or rectal irrigation – Used in cases where bowel incontinence is caused by faecal impaction and other treatments have failed to remove the impacted stool. A small tube is placed into the anus, while a special solution is used to wash out the rectum.
- Surgery – Only recommended for treatment after other options are attempted. Typical surgical treatments use sphincteroplasty (to repair damaged sphincter muscles) and sacral nerve stimulation (Electrodes stimulating the sacral nerves, helping the sphincter and pelvic floor muscles to work more effectively). Other treatments such as tibial nerve stimulation, endoscopic heat therapy and artificial sphincter surgery are less widely used.
- Incontinence products including disposable pads, pants and anal plugs may be recommended for use until symptoms controllable.
No matter what type of Incontinence you or the person you care for is experiencing it is important to discuss with a Health Professional. Incontinence is often a symptom of an underlying condition, which simple steps can often improve.