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Fecal incontinence

Fecal incontinence

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Fecal incontinence is the loss of regular control of the bowels. Involuntary excretion and leaking are common occurrences for those affected. Subjects relating to defecation
Defecation
Defecation is the final act of digestion by which organisms eliminate solid, semisolid or liquid waste material from the digestive tract via the anus. Waves of muscular contraction known as peristalsis in the walls of the colon move fecal matter through the digestive tract towards the rectum...

 are often socially unacceptable, thus those affected may be beset by feelings of shame and humiliation. Some do not seek medical help and instead attempt to self-manage the problem. This can lead to social withdrawal and isolation
Solitude
Solitude is a state of seclusion or isolation, i.e., lack of contact with people. It may stem from bad relationships, deliberate choice, infectious disease, mental disorders, neurological disorders or circumstances of employment or situation .Short-term solitude is often valued as a time when one...

, which can turn into cases of agoraphobia
Agoraphobia
Agoraphobia is an anxiety disorder defined as a morbid fear of having a panic attack or panic-like symptoms in a situation from which it is perceived to be difficult to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions...

. Such effects may be reduced by undergoing prescribed treatment, taking prescribed medicine and making dietary changes.

Prevalence


Fecal incontinence affects people of all ages, but is more common in older adults than in younger adults. It is not, however, a normal part of aging.

Constipation


Constipation causes prolonged muscle stretching and leads to weakness of the intestinal muscles. After a certain point, the rectum
Rectum
The rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long...

 will no longer close tightly enough to prevent stool
Human feces
Human feces , also known as a stool, is the waste product of the human digestive system including bacteria. It varies significantly in appearance, according to the state of the digestive system, diet and general health....

 loss, resulting in incontinence.

Muscle damage


Fecal incontinence can be caused by injury to one or both of the ring-like muscles at the end of the rectum called the internal and external anal sphincters. During normal function, these sphincters help retain stool
Human feces
Human feces , also known as a stool, is the waste product of the human digestive system including bacteria. It varies significantly in appearance, according to the state of the digestive system, diet and general health....

. In women, damage can occur during childbirth
Childbirth
Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...

. The risk of injury is greatest when the birth attendant
Birth attendant
A birth attendant, also known as “skilled birth attendant” , is a midwife, physician, obstetrician, nurse, or other health care professional who provides basic and emergency health care services to women and their newborns during pregnancy, childbirth and the postpartum period...

 uses forceps
Forceps in childbirth
Forceps are a surgical instrument that resembles a pair of tongs and can be used in surgery for grabbing, maneuvering, or removing various things within or from the body...

 to help the delivery or does an episiotomy
Episiotomy
An episiotomy , also known as perineotomy, is a surgically planned incision on the perineum and the posterior vaginal wall during second stage of labor. The incision, which can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic , and is sutured...

. Hemorrhoid
Hemorrhoid
Hemorrhoids or haemorrhoids , are vascular structures in the anal canal which help with stool control. They become pathological or piles when swollen or inflamed. In their physiological state they act as a cushion composed of arterio-venous channels and connective tissue that aid the passage of...

 surgery can damage the sphincters as well. A pelvic tumor
Pelvic tumor
A pelvic tumor is any one of numerous tumors that occur in the pelvis. Within the pelvis, these tumors may involve specific organs, or occupy intra-organ spaces. Tumors of the presacral space and sacral space are most prevalent in children...

 that grows in or becomes attached to the rectum
Rectum
The rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long...

 or anus
Anus
The anus is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, unwanted semi-solid matter produced during digestion, which, depending on the type of animal, may be one or more of: matter which the animal cannot digest,...

 also can cause muscle damage, as can surgery to remove the tumor. Although anal sex
Anal sex
Anal sex is the sex act in which the penis is inserted into the anus of a sexual partner. The term can also include other sexual acts involving the anus, including pegging, anilingus , fingering, and object insertion.Common misconception describes anal sex as practiced almost exclusively by gay men...

 resulting in repeated injury to the internal anal sphincter can lead to incontinence, the threat is relatively small. One study among 14 anoreceptive homosexual men and ten non-anoreceptive heterosexual men showed that anoreceptive homosexual men have decreased anal canal resting pressure relative to non-anoreceptive heterosexual men and no associated fecal incontinence. Another study among forty anoreceptive homosexual men and ten non-anoreceptive heterosexual men found a very significant increase in fecal incontinence (fourteen, or 35% amongst the anoreceptive men, and one, or 10% in the non-anoreceptive sample) amongst the anoreceptive sample.

Nerve damage


Fecal incontinence can also be caused by damage to the nerves that control the anal sphincters or to the nerves that detect stool in the rectum. Damage to the nerves controlling the sphincter muscles may render the muscles unable to work effectively. If the sensory nerves are damaged, detection of stool in the rectum is disabled, and one will not feel the need to defecate until too late. Nerve damage can be caused by childbirth, long-term constipation
Constipation
Constipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...

, stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...

, and diseases that cause nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...

 degeneration, such as diabetes and multiple sclerosis
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...

.

Loss of storage capacity


Normally, the rectum stretches to hold stool until it is voluntarily released. But rectal surgery, radiation
Radiation
In physics, radiation is a process in which energetic particles or energetic waves travel through a medium or space. There are two distinct types of radiation; ionizing and non-ionizing...

 treatment, and inflammatory bowel disease
Inflammatory bowel disease
In medicine, inflammatory bowel disease is a group of inflammatory conditions of the colon and small intestine. The major types of IBD are Crohn's disease and ulcerative colitis.-Classification:...

 can cause scarring, which may result in the walls of the rectum becoming stiff and less elastic. The rectum walls are unable to stretch as much and are unable to accommodate as much stool. Inflammatory bowel disease also can make rectal walls very irritated and thereby unable to contain stool.

Diarrhea



Diarrhea
Diarrhea
Diarrhea , also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and...

, or loose stool, is more difficult to control than solid stool that is formed. Where diarrhea is caused by temporary problems such as mild infections or food reactions, incontinence tends to last for a period of days. Chronic conditions, such as irritable bowel syndrome
Irritable bowel syndrome
Irritable bowel syndrome is a diagnosis of exclusion. It is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic cause. In some cases, the symptoms are relieved by bowel movements...

, or Crohn's disease
Crohn's disease
Crohn's disease, also known as regional enteritis, is a type of inflammatory bowel disease that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms...

 can cause severe diarrhea lasting for weeks or months until successful treatment can be found.

Pelvic floor dysfunction


Abnormalities of the pelvic floor
Pelvic floor
The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus, and associated connective tissue which span the area underneath the pelvis. The pelvic diaphragm is a muscular partition formed by the levatores ani and coccygei, with which may be included the...

 can lead to fecal incontinence. Examples of some abnormalities are decreased perception of rectal sensation, decreased anal canal pressures, decreased squeeze pressure of the anal canal, impaired anal sensation, a dropping down of the rectum (rectal prolapse
Rectal prolapse
Rectal prolapse normally describes a medical condition wherein the walls of the rectum protrude through the anus and hence become visible outside the body.-Types:There are three chief conditions which come under the title rectal prolapse:...

), protrusion of the rectum through the vagina (rectocele
Rectocele
A rectocele results from a tear in the rectovaginal septum . Rectal tissue bulges through this tear and into the vagina as a hernia...

), and generalized weakness and sagging of the pelvic floor.

Other causes


Fecal incontinence can have other causes including one or a combination of the following:
  • Excretory problems
    Excretion
    Excretion is the process by which waste products of metabolism and other non-useful materials are eliminated from an organism. This is primarily carried out by the lungs, kidneys and skin. This is in contrast with secretion, where the substance may have specific tasks after leaving the cell...

  • Fecal impaction
    Fecal impaction
    A fecal impaction is a solid, immobile bulk of human feces that can develop in the rectum as a result of chronic constipation.-Symptoms:Symptoms include chronic constipation. There can be fecal incontinence and paradoxical or overflow diarrhea as liquid stool passes around the obstruction. ...

  • Diseases, drugs, and indigestible dietary fats that interfere with the intestine
    Intestine
    In human anatomy, the intestine is the segment of the alimentary canal extending from the pyloric sphincter of the stomach to the anus and, in humans and other mammals, consists of two segments, the small intestine and the large intestine...

    al absorption. Respective examples include cystic fibrosis
    Cystic fibrosis
    Cystic fibrosis is a recessive genetic disease affecting most critically the lungs, and also the pancreas, liver, and intestine...

    , orlistat
    Orlistat
    Orlistat , also known as tetrahydrolipstatin, is a drug designed to treat obesity. Its primary function is preventing the absorption of fats from the human diet, thereby reducing caloric intake...

    , and olestra
    Olestra
    Olestra is a fat substitute that adds no fat, calories, or cholesterol to products. It has been used in the preparation of traditionally high-fat foods such as potato chips, thereby lowering or eliminating their fat content...

    .
  • Lateral internal sphincterotomy
    Lateral internal sphincterotomy
    Lateral internal sphincterotomy is an operation performed on the internal anal sphincter muscle for the treatment of chronic anal fissure. The internal anal sphincter is one of two muscles that comprise the anal sphincter which controls the passage of feces...

     (Surgical procedure for helping Anal fissure
    Anal fissure
    An anal fissure is a break or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on the toilet paper, sometimes in the toilet. If acute they may cause severe periodic pain after defecation but with chronic fissures pain intensity is often less...

    s heal)
  • Seizure

Severity scales


The Cleveland Clinic
Cleveland Clinic
The Cleveland Clinic is a multispecialty academic medical center located in Cleveland, Ohio, United States. The Cleveland Clinic is currently regarded as one of the top 4 hospitals in the United States as rated by U.S. News & World Report...

 Incontinence Score is widely used because it is practical and easy to use and interpret. The score takes into account the frequency of incontinence and the use of pads and lifestyle alteration. A Fecal Incontinence Severity Index is based on a type-by-frequency matrix with four types of leakage (gas, mucus, liquid stool, solid stool) and five frequencies (one to three times per month, once per week, twice per week, once per day, twice or more per day).

Other tests include: AMS, Pescatori, Williams score, Kirwan, Miller score, Parks criteria, and the Vaizey scale.

Tests


Anorectal Manometry checks the tightness of the anal sphincter and its ability to respond to signals, as well as the sensitivity and function of the rectum. Endoanal ultrasound evaluates the structure of the anal sphincters. Proctography, also known as defecography, shows how much stool the rectum can hold, how well the rectum holds it, and how well the rectum can evacuate the stool. Proctosigmoidoscopy allows doctors to look inside the rectum for signs of disease or other problems that could cause fecal incontinence, such as inflammation, tumors, or scar tissue. Anal electromyography tests for nerve damage, which is often associated with obstetric injury.

Treatment


Treatment depends on the cause and severity of fecal incontinence; it may include dietary changes, medication, bowel training, or surgery. More than one treatment may be necessary because some forms of fecal incontinence can be rather complicated. Most physicians that specialize in gastroenterology
Gastroenterology
Gastroenterology is the branch of medicine whereby the digestive system and its disorders are studied. The name is a combination of three Ancient Greek words gaster , enteron , and logos...

, rehabilitative medicine, neurotrauma, and pediatric surgery have experience with bowel management programs. "Social continence" may be achievable for some people using a bowel management program that cleans out the colon daily. Cecostomy tube placement with antegrade enemas may benefit some patients.

Dietary changes


Food affects the consistency of stool and how quickly it passes through the digestive system. One way to help control fecal incontinence in some persons is to eat foods that add bulk to stool, decreasing the water content of the feces and making it firmer. Also, avoidance of foods and drinks such as those containing caffeine, which relax the internal anal sphincter muscle. Another approach is to eat foods low in fiber to decrease the work of the anal sphincters. Fruit can act as a natural laxative and should be eaten sparingly. Foods to be avoided also include those that typically cause diarrhea, such as cured
Curing (food preservation)
Curing refers to various food preservation and flavoring processes, especially of meat or fish, by the addition of a combination of salt, nitrates, nitrite or sugar. Many curing processes also involve smoking, the process of flavoring, or cooking...

 or smoked meat
Meat
Meat is animal flesh that is used as food. Most often, this means the skeletal muscle and associated fat and other tissues, but it may also describe other edible tissues such as organs and offal...

; spicy
Spice
A spice is a dried seed, fruit, root, bark, or vegetative substance used in nutritionally insignificant quantities as a food additive for flavor, color, or as a preservative that kills harmful bacteria or prevents their growth. It may be used to flavour a dish or to hide other flavours...

 foods; alcohol
Alcohol
In chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....

; dairy products; fatty and greasy foods; and artificial sweeteners.

Surgery


Surgical
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 procedures used to treat otherwise intractable fecal incontinence include:
  • Colostomy
    Colostomy
    A colostomy is a surgical procedure in which a stoma is formed by drawing the healthy end of the large intestine or colon through an incision in the anterior abdominal wall and suturing it into place. This opening, in conjunction with the attached stoma appliance, provides an alternative channel...


  • Cecostomy with antegrade enema program

  • Stimulated graciloplasty creates a new anal sphincter, using gracilis muscle
    Gracilis muscle
    The gracilis is the most superficial muscle on the medial side of the thigh. It is thin and flattened, broad above, narrow and tapering below.-Origin and insertion:...

     from the thigh
    Thigh
    In humans the thigh is the area between the pelvis and the knee. Anatomically, it is part of the lower limb.The single bone in the thigh is called the femur...

     and a temporary electric device to retrain the muscle for its new function.

  • Artificial anal sphincter (also known as "artificial bowel sphincter" and "neosphincter"). The usual surgical approach is through the perineum
    Perineum
    In human anatomy, the perineum is a region of the body including the perineal body and surrounding structures...

     but because in many cases of fecal incontinence the perineum is damaged, for women an alternative approach is through the vagina
    Vagina
    The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the...

    .

  • Temperature-controlled radiofrequency energy (SECCA)

  • Antegrade continent enema stoma. This procedure is often necessary in addition to others when fecal incontinence is complicated by neuropathy and/or an incomplete internal anal sphincter.



Graciloplasty and artificial anal sphincter both significantly improve continence, with artificial anal sphincter being superior, however both methods have high rates of complications.

Kegel exercises


Appropriate exercise of the sphincter muscles (Kegel exercise
Kegel exercise
A pelvic floor exercise, more commonly called a Kegel exercise , consists of contracting and relaxing the muscles that form part of the pelvic floor, which are now sometimes colloquially referred to as the "Kegel muscles". Several tools exist to help with these exercises, though many are ineffective...

) can help restore muscle tone, and reduce or even eliminate anal incontinence.

External links