Fecal Incontinence

The ability to control bowel movements and the passage of gas is something we all take for granted. We’ve all experienced the occasional accident, but for most of us, it’s not a way of life. Fecal incontinence (FI) should be considered when “accidents” occur more regularly and when no underlying gastrointestinal disease (such as Crohn’s disease or ulcerative colitis) is present.

By definition, fecal incontinence is the involuntary loss of stool or soiling at a socially inappropriate time or place. To meet the ROME II criteria for fecal incontinence, you must have recurrent uncontrolled passage of fecal material for at least one month and must be over the age of four years old. (In 1988, at the 13th International Congress of Gastroenterology in Rome, Italy, a group of physicians defined criteria to more accurately diagnose irritable bowel syndrome [IBS]. Known as the “Rome Criteria,” this set of guidelines that outlines symptoms and applies parameters such as frequency and duration make possible a more accurate diagnosis of IBS. They have expanded their scope to include all functional disorders of the GI tract.)

Fecal incontinence is not only embarrassing, but can lead to social isolation and depression in otherwise healthy people. Due to the stigma surrounding this problem, people are reluctant to mention their symptoms, even to their doctors. Unfortunately, FI is a fairly common problem. While the true prevalence is unknown, it is thought to affect as much as 3 percent of the general adult population. If you look at specific high risk groups such as elderly nursing home residents, diabetics and individuals with multiple sclerosis, the prevalence is much higher. In fact, fecal incontinence is one of the leading causes of nursing home placement.

The impact of fecal incontinence on the quality of life can be physically and psychologically devastating. It can lead to loss of independence, isolation, and an altered sense of self. The social and economic impact on society is poorly quantified.

We know that over $400 million each year is spent on adult diapers alone. When you factor in lost wages, time off from work (for patient and/or family), and physician or allied health profession encounters, it becomes clear that this is a multi-billion dollar problem.

Typically, someone with damage to the external sphincter has “urgent incontinence,” whereas someone with damage to the internal sphincter has passive soiling or “leakage." Aside from damage to the external and internal anal sphincters, diarrhea, chronic constipation, impacted stool, nerve injury or disease may also be the cause of incontinence. Determining the cause is vital before deciding on a course of treatment.

During the physical exam, the doctor will start with a digital exam of the anus and rectum. Here the physician checks for sphincter defects, muscle tone and, of course, tumors. Medical staff then attach tiny electrodes for the electromyography, which checks for neurologic or muscular causes of poor anal sphincter function. A small catheter with a balloon on the end is next inserted into the rectum for the anal manometry. The catheter we use in our clinic is a fourchannel radial Zinetics Manometric Catheter.

Anal manometry measures the internal pressure in the lower digestive tract. It’s helpful in revealing poor tone of the anal sphincters and helps determine if rectal sensation and rectal reflexes are impaired. For pudendal nerve testing, a small stimulating electrode on the end of the doctor’s gloved finger is inserted into the rectum. Several mild electrical impulses are delivered, and nerve conduction or nerve damage is determined. The patient may sense the impulse for a few seconds but any discomfort is very mild.

Anorectal ultrasound is next and can reveal abnormalities of the anal sphincters, the rectal wall, and the pelvic muscles that help maintain continence. This test is the safest and most reliable test for identifying structural abnormalities of both anal sphincters. To complete our testing, the patient undergoes a defacography. This procedure involves placing a barium paste into the rectum. X-rays are then taken during rest, straining, and defecation of the paste.

Defacography takes place in the radiology department. The patients are placed on a specially-made commode in a private room. By the time we see these patients, they are so anxious for a solution to their problem, they are able to overcome any privacy issues.

First, treatment of underlying medical disorders such as laxative abuse, liquid stool from infection, and inflammatory conditions of the colon and rectum should be addressed.

Next, we would focus on dietary changes. Avoiding substances that may cause diarrhea, such as alcohol, caffeine, and lactose, is recommended. A diet high in fiber helps to thicken the stool and decrease the amount of liquid stool. A formed stool is much easier to hold and to pass then a liquid stool.

Patients who have fecal incontinence due to fecal impaction would be disimpacted first, then started on dietary management as noted above. Toileting routines (taking the same time each day to sit and evacuate), may also be helpful. The next step in non-surgical management is pharmacological therapy. The addition of anti-diarrhea/constipating agents such as Lomotil, Imodium, and cholesteramine may help to slow GI transit, increase fluid absorption and decrease mucus production.

If fecal incontinence is thought to be due to lack of sphincter control or decreased sensation, a bowel training program with exercise called anorectal biofeedback may be prescribed. Biofeedback is a safe and relatively noninvasive way of treating incontinence. It is especially effective if the patient’s main complaint is urgency and there are no major defects noted in the sphincter muscles. Small sensors are placed on the anus and the abdomen. Visual feedback helps the patient identify and contract the muscles that help maintain continence.

In our center, a large part of biofeedback also entails spending time with the patient and helping them to develop coping skills.

During biofeedback, the main impact is on strengthening the muscles of the anus and rectum. We help patients to develop realistic expectations and goals with relation to their own individual problem. As mentioned, we recommend the patient develop a bowel habit. This would entail attempting to evacuate at the same time every day, preferably early. This would leave the bowel empty with less chance of an accident. Biofeedback helps them to recognize their own bodily signs and to not wait until the last minute before locating a bathroom. We also recommend the patient carry a change of underwear, premoistened wipes, and a plastic bag for disposal of soiled items. Allowing the patient to feel more in control of their symptoms helps to relieve anxiety.

For some people, treatment of fecal incontinence requires surgery to correct the underlying problem. Certain problems respond to surgery better than others. Anal sphincter damage caused by childbirth or rectal prolapse, for example, can often be successfully treated with surgery.

Rectal prolapse is a condition in which the rectum turns itself inside out. In the earliest phases of this condition, the rectum does not stick out of the body, but as the condition worsens, it may protrude. Weakness of the anal sphincter muscle is often associated with rectal prolapse at this stage and may result in leakage of stool or mucus. The condition occurs in both sexes, although it is more common in women than men.

Surgical options to treat fecal incontinence include:

• Sphincteroplasty
• Surgical repair of rectal prolapse, rectocele, or hemorrhoids
• Colostomy

Overlapping sphicteroplasty is the procedure of choice for patients with a documented sphincter defect. This procedure works best if there is no underlying pudendal nerve damage. The procedure is done in an outpatient setting and usually only requires local anesthesia and sedation. The same applies for patients with prolapsing hemorrhoids, which can sometimes cause seepage. Repair of rectal prolapse is usually more involved and may require an abdominal or pelvic procedure. This usually requires at least one overnight stay but may necessitate a several night stay for a transabdominal repair with a resection. Highly specialized procedures such as sacral nerve stimulation, graciloplasty, and placement of an artificial bowel sphincter (ABS) are available on a limited basis, often as part of a research protocol. Colostomy may be used as definitive treatment or as an adjunct to any one of the surgical procedures mentioned above.