Fecal incontinence and its treatment
Fecal incontinence is a disturbance or inability to retain stool, causing involuntary leakage from the rectum. In the West it is also called "bowel incontinence." Its severity varies between individuals, ranging from a few drops seeping out to a complete loss of control. Whatever the cause, fecal incontinence can be extremely embarrassing. Many people feel ashamed and do not consult a doctor, yet in most cases treatment can lead to improvement.
Fecal incontinence is a disturbance or inability to retain stool, causing involuntary leakage from the rectum. In the West it is also called "bowel incontinence." Its severity varies between individuals, ranging from a few drops seeping out to a complete loss of control. Whatever the cause, fecal incontinence can be extremely embarrassing. Many people feel ashamed and do not consult a doctor, yet in most cases treatment can lead to improvement.
Symptoms
Temporary fecal incontinence can occur during an episode of "occasional" diarrhea when the urge is so sudden and strong that you cannot reach the toilet in time.
We speak of true fecal incontinence when the condition is chronic and recurrent.
There are two forms:
- Passive incontinence: there is no urge to defecate, yet stool still "marks" the underwear or is expelled spontaneously. This can be caused by weakening or nerve damage of the anal sphincter muscles.
- Urge incontinence: The patient cannot stop the bowel movement; the urge arrives so suddenly that they cannot reach the toilet in time.
Fecal incontinence can cause anxiety and depression. The affected person may be embarrassed to tell their doctor. There are several treatments that can improve or even completely eliminate the condition. If you wait for years and neglect it, you reduce the chances of recovery. The sooner you start treatment, the better the chance of resolution.
Causes of fecal incontinence
- Muscle damage. Injury or damage to the sphincter rings above the anus can occur during childbirth, especially with an episiotomy. The muscles can also be injured during anal sexual intercourse, for example when overly large devices are used.
- Nerve damage. The rectum is full of sensory nerve endings that detect stretching by stool and initiate the sensation to defecate. The anal sphincter itself is also under neural control: part of its function is involuntary closure of the opening, and part is voluntary opening. If either sensory or motor nerve fibers are damaged, fecal incontinence can result. Common causes of nerve damage include childbirth, spinal cord injury, stroke, and injuries occurring during prostate surgery. Diabetes and multiple sclerosis can also damage nerves and lead to incontinence.
- Constipation. When bowel movements slow, stool spends a long time in the bowel and intestinal villi absorb almost all its moisture. The stool becomes dry and hard, forming a large mass that can become impacted at the outlet. People with constipation strain heavily and bear down during bowel movements, which stretches and gradually weakens the anal sphincter muscles. This leads to stool leakage. Chronic constipation can also cause nerve damage, worsening the situation.
- Diarrhea. Solid stool is easier to retain in the rectum than loose stool, so diarrhea (usually temporary) can cause or worsen fecal incontinence.
- Hemorrhoids. Swollen, dilated veins of the rectum (hemorrhoids) can prevent the anal opening from closing completely, allowing stool to drip.
- Scarring. Normally the rectum can stretch considerably to accommodate stool. Radiation therapy or inflammatory bowel disease can cause scarring of the rectum, making the bowel wall rigid and unable to expand adequately, so excess stool may be squeezed out.
- Surgical injury. Hemorrhoid surgeries or operations on the rectum and pelvic organs can cause muscle and nerve damage.
- Prolapse (rectal prolapse). In rectal mucosal prolapse, the mucosa appears in the anal opening, and in severe cases the rectum may turn outwards. Straining during constipation or strong bearing down during defecation, chronic hemorrhoid problems, and rectal polyps can contribute to its development.
- Rectocele. A rectocele develops when the posterior vaginal wall bulges into the vagina. It can result from congenital connective tissue weakness or inadequately repaired vaginal childbirth injuries.
Treatment options
Fecal incontinence can occur at any age but is more common in adults over 65. It is more frequent in women because it can be a complication of childbirth. Recent studies have also shown that women on hormone replacement therapy for menopause may experience fecal incontinence more often.
Treating fecal incontinence is important for several reasons.
First, the loss of the ability to retain stool can cause humiliation, shame, anxiety, and depression. It is common for affected people to try to "hide the problem" by avoiding contact with others and withdrawing socially.
Second, the skin around the anus is delicate and sensitive; exposure to stool can cause excoriation, pain, and itching.
Management of treatment requires a trained specialist who will advise which methods to use and how to use them. Many treatments can now be performed at home, so daily clinic visits are not (or should not be) necessary.
Prevention
Prevention is possible in many cases. The following may help:
- Reduce constipation – increase physical activity (walk, jog, exercise regularly), eat more vegetables and fruits, consume high-fiber foods, and drink plenty of fluids.
- Treat the cause of diarrhea when it is due to intestinal infection.
- Avoid straining during bowel movements – excessive straining can gradually weaken your anal sphincter muscles or even damage the nerves.
One goal of treating fecal incontinence is to teach you how to strengthen your pelvic floor muscles so you can sense when it is time to empty your bowels and be able to contract your sphincter muscles.
Pelvic floor exercises
A daily "exercise" in which you voluntarily tighten the anal sphincter. The effect is expected after months of regular training. Although this is the cheapest and simplest home treatment for fecal incontinence, it is also the slowest. Muscle stimulation can achieve results in a significantly shorter time.
Electrotherapy and biofeedback
Biofeedback
A device that, using a sensor probe placed in the anus, assists pelvic floor training.
Sensing can occur in two ways.
- By detecting the muscle's electrical activity (EMG). When you voluntarily try to tighten the sphincter muscles, the device senses the signal coming from the brain to the muscles, even if it is very weak.
- By detecting the pressure exerted by the sphincter muscles. In this case the device senses the squeezing force (actually pressure) produced by the sphincter.
The point of both methods is that the device detects the muscle contraction and gives feedback. For example, it may indicate contraction strength with a number or a light. The biofeedback device itself does not treat; it helps you learn to perform the exercise most effectively. With biofeedback you can achieve results faster and more effectively than with pelvic floor exercises alone.
FES, that is, functional electrical stimulation
In this method a device assists training of the pelvic floor sphincter muscles by directly stimulating the pelvic floor muscles through an electrode placed in the anus. It is a passive method, meaning it treats without you having to do anything.
With muscle stimulation both muscle weakness and excessive muscle activity can be treated – of course different programs are needed for strengthening and for relaxation. Muscle stimulation also helps when incontinence is caused by damage or other problems affecting the motor nerve running to the sphincter, so you may not even be able to perform voluntary exercises.
Another advantage of the method is the "retraining" of nerves running to the sphincter muscles. In cases of an overactive sphincter, stimulation can relax the muscle and help it "learn" the relaxed state.
The stimulator device is easy to use and the intimate treatment can be performed safely at home without the doctor's presence.
Stimulation produces results much faster than pelvic floor exercises. With regular daily treatment the muscles strengthen/relax and stool retention/evacuation become controllable again. The first results can be experienced after 2–3 weeks, but treatment should be continued for 8–10 weeks. The results achieved by then should be maintained with supportive treatment, for example regular pelvic floor exercises or 1–2 stimulations per week. (If you stop the treatments completely, the problem may return over time.)
ETS device
The most modern and most effective incontinence treatment device is the ETS, i.e., biofeedback-triggered muscle stimulation treatment.
A probe placed in the anus senses when you voluntarily tighten the muscles. At a preset "squeezing" threshold the device "assists," meaning it reinforces the sphincter with stimulation impulses delivered through the probe. This makes the muscle contraction more effective.
The ETS, i.e., the combined biofeedback + stimulator device, provides the most effective method of treating incontinence.
Incontinence treatment devices
Both fecal and urinary incontinence can be treated with several methods. Muscle stimulation is one of the most effective. After 2–3 weeks of treatment you can feel beneficial effects, and persistent treatment in most cases completely eliminates or at least significantly reduces symptoms.
