Faecal incontinence is a symptom of bowel (anorectal) dysfunction, occurring as a result of a dysfunctional coordination of the internal and external sphincter muscles, and pelvic floor muscles. If you suffer from faecal incontinence you will uncontrollably pass gas, and leak liquid and/or solid faeces occasionally, or multiple times a day.
The internal sphincter is unconsciously contracted throughout the day, holding waste matter in the rectum until there is enough to warrant a bowel movement. If the sphincter becomes damaged then you can lose the sensation to go to the bathroom, and it can open to allow soft or small pieces of stool to leak without you realising. This often occurs when you are moving, and is known as passive faecal incontinence.
The external sphincter is voluntarily relaxed until your rectum becomes full, at which point the internal sphincter gives the sensation to go to the toilet and you contract this sphincter. You will then relax both sphincters to relieve yourself in a toilet. If this muscle gets damaged you can expect the urge to go the bathroom to be quickly followed by a uncontrollable bowel movement as you are unable to contract the external sphincter enough. This is known as urge faecal incontinence.
Bowel incontinence can really damage your self-esteem and quality of life. It can result in depression, anxiety, and social isolation, as you become no longer comfortable leaving the house. It is the number one reason for an elderly person to be institutionalised, with 30-50% of nursing home residents suffering from faecal incontinence. If you are suffering, take comfort in knowing that you are not alone. Bowel incontinence is more common that asthma and diabetes, reports suggest it affects over 53 million Europeans (figure from Bladder & Bowel Support Company, 2018) and 5.5 million Americans (figure from American College of Gastroenterology, 2013), however, the true figure is likely to be even greater.
Treatments for faecal incontinence are widely available, and often bowel incontinence can be treated with conservative (non-pharmaceutical) therapy's alone.
Symptoms of Faecal Incontinence
You may be suffering from faecal incontinence if you:
- pass small pieces of stool when you pass wind
- pass very soft and liquid stool (diarrhoea), often without realising
- are unable to prevent wind from escaping
- occasionally experience a complete loss of bowel control and pass solid stool
- suffer from chronic diarrhoea
- suffer from fecal impaction or constipation
- frequently soil your underwear
- often suffer from stomach pain
- suffer from urinary incontinence
Get a formal diagnosis from your GP to confirm that the symptoms you are experiencing are not part of another more serious condition, such as rectal cancer or Irritable Bowel Syndrome (IBS). Other symptoms of these conditions include; bleeding, pain, a feeling of never having an empty bowel, dark or black stools, and/or unexplained weight loss.
Causes of Faecal Incontinence
Damage to your internal and external anal sphincter and pelvic floor muscles can occur as a result of one or more of the following causes:
- Childbirth - In otherwise healthy women, childbirth is the leading cause of incontinence. Reports suggest that up to 13% of women that have had a single birth have symptoms of faecal incontinence. With multiple births increasing this risk to 20%. These figures are predicted to be much higher than reported, as many women do not seek diagnosis due to embarrassment. Childbirth can damage and weaken the sphincter muscles, often causing nerve damage and in some cases tear the anal sphincter.
- Pelvic floor dysfunction - A weak pelvic floor can lead to a rectocele (rectal prolapse) where the rectum protrudes into the vagina. It can also cause an enterocele, where the small intestine prolapses into the space between the rectum and vagina. 50% of constipation is due to pelvic floor dysfunction, where the muscles are unable to relax when you attempt to defecate.
- Constipation - Constipation can lead to faecal incontinence in two ways: 1) Chronic straining can weaken your pelvic floor, preventing your muscles from being able to support your colon, and move matter through it. 2) If you have extremely hard, impacted faeces, your body will produce more liquid in an attempt to soften it. This can lead to orange/light brown diarrhoea that can more easily leak.
- Diarrhoea - Temporary (acute) diarrhoea can occur as a result of a mild infection or food reaction. Chronic recurring diarrhoea can occur as a symptom of Irritable Bowel Syndrome and Chrohn's disease. Diarrhoea can more easily leak through a damaged or weak sphincter. Even if your sphincters would normally function acceptably, extremely loose and wet stool can leak.
- Disease and injury - If you suffer from Parkinson’s disease, Multiple Sclerosis, Stroke, a spinal cord injury, Alzheimer’s, spina bifida or diabetes, you are at a greater risk of developing faecal incontinence due to the nerve damage that your pelvis may have. You can lose the sensation of needing the toilet, not realise when your bowel is full or whether you will pass wind or liquid stool. If your muscles are damaged, you will lose control over how and when you open your bowels.
- Sexual abuse - Some forms of sexual abuse damage the sphincter muscles. Sexual abuse can also cause anxiety around defecation.
- Medications - Some medications can interfere with the absorption of dietary fats in the intestine. Antibiotics can loosen your stools and cause diarrhoea, making your symptoms worse. Never stop taking a prescribed medication without first consulting your GP.
- Surgery - Any pelvic surgery can damage the sphincter. Surgeries which occur in or around the anus are more likely to cause damage, with anorectal (anus and rectum) and colorectal (colon) surgeries having the greatest risk.
- Carrying excess body weight - Carrying excess weight puts unnecessary weight on your pelvic floor and increases the intra-abdominal pressure. If you were previously obese and underwent surgery in an attempt to resolve it, such as a gastric bypass, you are likely to still experience bowel incontinence as the surgery does not resolve any previous damage done.
- Age - As you age your diet will change as a result of losing your appetite, or if you can no longer eat certain things. 67% of bowel incontinence in elderly patients can be treated by reviewing the sufferers diet. Another age associated cause of incontinence is muscle atrophy as you become less mobile, this includes your pelvic floor muscles which will be less able to support normal bladder and bowel function.
- Smoking - Its no secret that smoking can lead to a huge list of health problems. There are many diseases and dysfunctions that it can cause in your digestive system, including; cancers, peptic ulcers, liver disease, increased symptoms of Chrohn's disease, colon polyps and pancreatitis. The chronic cough that often accompanies smoking will also strain and weaken your pelvic floor.
To read more about these causes, and the events that can lead to you developing any form of incontinence, visit the Causes and Diagnosis page.
How to Stop Faecal Incontinence
Faecal incontinence should be considered a lifelong condition which you treat by amending your lifestyle.
Conservative therapy's, such as lifestyle changes and non-surgical medical treatments, resolve 25% of incontinence cases, and are the first course of treatment.
- Pelvic floor (Kegel) exercises - Your pelvic floor is responsible for supporting your bowels, and the muscles of it are responsible for moving waste through the lower digestive system and out of the anus. Regularly exercising it will improve the strength of you sphincters and the coordination of their contraction in response to the urge to go.
- Biofeedback therapy - Learning how to effectively contract and relax the pelvic floor muscles can help you learn how best to defecate. This is the role of biofeedback therapy, where your doctor will ensure you are correctly exercising your pelvic floor. It can be done using an electrical device with an anal probe, vaginal probe or external skin electrodes. These feedback the movements of the muscles with a score, so you are able to see an improvement as you progress with your exercises. Biofeedback therapy can also include rectal sensitivity training, which aims to improve the sensitivity of the rectum so you can detect the urge to defecate earlier. This involves an intra-rectal balloon, which is placed in the rectum and progressively shrank over repeated re-inflation's. This can also be used in a patient that suffers from hypersensitivity as it teaches them to tolerate progressively larger volumes before defecating.
- Neuromuscular stimulation (NMES) - To enhance the effectiveness of your pelvic floor exercises you can use an electronic pelvic floor toner. Many toners use NMES which stimulate the nerves with electrical pulses to contract the muscles artificially, targeting both fast twitch and slow twitch fibres to increase both endurance and your ability to resist sudden urges to defecate. NMES also increases circulation and the bulk and strength of your muscles and, by association, the function of the pelvic floor in maintaining normal bowel movements.
- Treat acute diarrhoea - If you are suffering from temporary (acute) diarrhoea, you will be advised to drink more water to prevent dehydration, and contact your GP if it does not stop within a few days for further advise. At which point you may be prescribed with an anti-diarrheal agent; such as loperamide, codeine or diphenoxylate. These increase the time matter is in the intestine by inhibiting the muscles, resulting in firmer faeces when it reaches your rectum. These drugs also enhance the strength of the sphincter to resist urges. A common side effect of these drugs is constipation when they are taken in too high a dose.
- Treat and prevent constipation - Increase your intake of fibre and drink more water. Pelvic floor exercises can also improve the ease of your bowel movements, with 50% of constipation due to pelvic floor dysfunction. Your doctor can prescribe stool softeners or laxatives if you are unable to treat the constipation without. You may be offered a tap-water enema or rectal suppository as a quicker resolution.
Stop smoking, maintain a healthy weight (BMI under 30) and exercise.
- Review your diet - An altered diet can be successful in treating bowel incontinence in 67% of elderly sufferers, and 1/3 of other sufferers.
- Add fibre to make your faeces firmer.
- Eat probiotic yogurts to introduce healthy bacteria into your gut.
- Eat tomatoes, bananas and garlic - they stimulate the growth of good bacteria as they contain prebiotics.
- Avoid caffeine which stimulates and relaxes the internal sphincter muscle.
- Avoid dairy, fruit and artificial sweeteners which make your faeces loose.
- Reduce your intake of sodium (salt) and protein which can increase the production of wind.
Surgery should not be considered as a one-time solution to resolve incontinence. Incontinence should be considered as a life-long condition that we all have to manage and prevent throughout our life. Even if you have surgery, your surgeon will expect you to review your lifestyle and introduce pelvic floor muscles into your routine to prevent incontinence from returning. Most surgeries aim to enhance the strength of the internal and external anal sphincters. The National Institute for Health and Care Excellence publish recommendations for surgical procedures, and for faecal incontinence they recommend most procedures are performed within units that specialise in faecal incontinence, where appropriate support is available.
- Weight reduction - Surgery to reduce obesity, i.e. gastric bypass, is unable to treat bowel incontinence, as it does not resolve the damage to the sphincter muscles. It can, however, treat one of the causes of incontinence and be successful in preventing incontinence from getting worse.
- Injectable bulking agents - Under local anaesthetic, bulking agents can be injected into your weak or damaged sphincters to increase their strength.
- Sphincter repair - This surgery overlaps weak or damaged internal and external sphincters to increase bulk and create a complete ring of muscle.
- Artificial sphincter - A damaged (or significantly weak) anal sphincter can be added to with an inflatable cuff. This cuff is connected to a pump (placed in the labia in women and scrotum in men) and a balloon (in the abdomen). The cuff is filled with fluid to keep the anus closed. When you go to the toilet, you activate the pump to move the fluid to the balloon, allowing the cuff to empty and relax, allowing for defecation. The National Institute for Health and Care Excellence currently recommend this procedure is only done within the context of research.
- Implanted magnetic bead band - If you have weak or damaged sphincters, you may be offered this relatively new procedure. A tunnel is made around the anus, into which a ring of magnetic beads is placed. The magnets keep the sphincter closed, until stool presses against it to interfere and open the ring. The National Institute for Health and Care Excellence recommend this procedure due to the significant improvement in quality of life that it can provide. However they do highlight that more research into the procedures effectiveness and safety needs to be done.
- Nerve stimulation - In a series of outpatient sessions, a mild electric current is passed from a needle into the tibial nerve, which is above the ankle. This nerve connects to the pelvic floor and hence these electrical pulses can strengthen its muscles. If you have a weak, but otherwise intact sphincter, you can have a procedure where electrodes are semi-permanently implanted under the skin of the lower back. They are connected to a pulse generator which produces electrical pulses through the sacral nerve, keeping the anal sphincter closed. When you need to defecate you use a magnet to interrupt the pulses of electricity to allow your sphincter to relax. A series of testing and training allows your surgeon to adjust the device to work most effectively for you, and for you to learn how best to use it.
- Muscle transposition - A segment of the gracilis muscle, from the patients thigh, is added to the anus as extra bulk. An electric pulse generator is implanted into the abdomen which continuously stimulates the muscle, turning it into a slow twitch endurance muscle.
- Ileostomy/colostomy - These permanent stomas are considered as a suitable treatment where other surgeries have failed. An ileostomy is where the small bowel (small intestine) is diverted through an opening in the abdomen into a bag. A colostomy is where the end of the colon is diverted through an opening in the abdomen into a bag. These avoid the lowest part of the digestive system, and does not treat the causes of incontinence.
If you are suffering with depression, associated with your incontinence, speak to your doctor to support you during your treatment. To read about the other treatments available for general incontinence, and the potential complications associated with surgical treatments, visit our incontinence treatment page.
Altman, D. Falconer, C. Rossner, S. Melin, I. (2007). International Urogynecology Journal. The risk of anal incontinence in obese women. [online] 18(11), p1283-1289 [viewed 26/04/18]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17356799
Bharucha, A. E. (2013). Fecal Incontinence. [online] American College of Gastroenterology, 2013. [viewed 27/04/18]. Available from: http://patients.gi.org/topics/fecal-incontinence/
Bladder and Bowel Support Company (2018). Faecal Incontinence. [online] Bladder and Bowel Community. [viewed 25/04/18]. Available from: https://www.bladderandbowel.org/bowel/bowel-problems/faecal-incontinence/
Bliss, D. Z. Fischer, L. R. Savik, K. (2005). Journal of Gerontological Nursing. Managing fecal incontinence: self-care practices of older adults. [online] 31(7), p35-44. [viewed 26/04/18]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16047958
Carter, D. (2014). Gastroenterology. Conservative treatment for anal incontinence. [online] 2(2), p85-91. [viewed 26/04/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4020129/#__ffn_sectitle
Croswell, E. Bliss, D. Z. Savik, K. (2010). Journal of wound, ostomy, and continence nursing. Diet and Eating Pattern Modifications Used by Community Living Adults to Manage Their Fecal Incontinence. [online] 37(6), p677-682. [viewed 26/04/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2994718/?report=reader
Halverson, A. L. Hull, T. L. (2002). Diseases of the Colon & Rectum. Long-Term Outcome of Overlapping Anal Sphincter Repair. [online] 45(3), p345-348. [viewed 27/04/18]. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=linkout&SEARCH=12068192.ui
Heymen, S. Scarlett, Y. Jones, K. Ringel, Y. Drossman, D. Whitehead, W. E. (2009). Diseases of the colon and rectum. Randomized Controlled Trial Shows Biofeedback to be Superior to Alternative Treatments for Patients with Pelvic Floor Dyssynergia-type Constipation. [online] 52(10), doi: 10.1007/DCR.0b013e3181b55455. [viewed 26/04/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3855426/#__ffn_sectitle
Højberg, K-E. Salvig, J. D. Winsløw, N. A. Bek, K. M. Laurberg, S. Secher, N. J. (2000). British Journal of Obstetrics and Gynaecology. Flatus and faecal incontinence: prevalence and risk factors at 16 weeks of gestation. [online] 107, p1097-1103. [viewed 26/04/18]. Available from: https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1471-0528.2000.tb11107.x
Hull, T. (2007). Clinics in Colon and Rectal Surgery. Fecal Incontinence. [online] 20(2), 118-124. [viewed 26/04/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780180/
Melville, J. L. Fan, M. Y. Newton, K. Fenner, D. (2005) American Journal of Obstetrics & Gynecology. Fecal incontinence in US women: A population-based study. [online] 193(6), p2071-2076. [viewed 26/04/18]. Available from: https://www.ajog.org/article/S0002-9378(05)01087-2/fulltext
NHS Trust. (2016). Ileostomy: Overview. [online] NHS Trust, 2016. [viewed 26/04/18]. Available from: https://www.nhs.uk/conditions/ileostomy/
NHS Trust. (2017a).Spina bifida: Overview. [online] NHS Trust, 2017. [viewed 26/04/18]. Available from: https://www.nhs.uk/conditions/spina-bifida/
NHS Trust. (2017b).Colostomy: Overview. [online] NHS Trust, 2017. [viewed 26/04/18]. Available from: https://www.nhs.uk/conditions/Colostomy/
NHS Trust. (2018).Crohn's disease: Overview. [online] NHS Trust, 2017. [viewed 26/04/18]. Available from: https://www.nhs.uk/conditions/crohns-disease/
NICE. (2004a). Artificial anal sphincter implantation. [online] National Institute for Health and Care Excellence, 2004. [viewed 27/04/18]. Available from: https://www.nice.org.uk/guidance/ipg66/resources/artificial-anal-sphincter-implantation-pdf-52774283783365
NICE. (2004b). Artificial anal sphincter implantation. [online] National Institute for Health and Care Excellence, 2004. [viewed 27/04/18]. Available from: https://www.nice.org.uk/guidance/ipg66/resources/artificial-anal-sphincter-implantation-pdf-257170429
NICE. (2004c). Sacral nerve stimulation for faecal incontinence. [online] National Institute for Health and Care Excellence, 2004. [viewed 27/04/18]. Available from: https://www.nice.org.uk/guidance/ipg99/resources/sacral-nerve-stimulation-for-faecal-incontinence-pdf-302618557
NICE. (2006). Stimulated graciloplasty for faecal incontinence. [online] National Institute for Health and Care Excellence, 2006. [viewed 27/04/18]. Available from: https://www.nice.org.uk/guidance/ipg159/resources/stimulated-graciloplasty-for-faecal-incontinence-pdf-304431661
NICE. (2007). Treating faecal incontinence with injectable bulking agents.[online] National Institute for Health and Care Excellence, 2007. [viewed 27/04/18]. Available from: https://www.nice.org.uk/guidance/ipg210/resources/treating-faecal-incontinence-with-injectable-bulking-agents-pdf-307517437
NICE. (2011). Treating faecal incontinence by stimulating the tibial nerve near the ankle. [online] National Institute for Health and Care Excellence, 2011. [viewed 27/04/18]. Available from: https://www.nice.org.uk/guidance/ipg395/resources/treating-faecal-incontinence-by-stimulating-the-tibial-nerve-near-the-ankle-pdf-317727325
NICE. (2014). Inserting a magnetic bead band for faecal incontinence. [online] National Institute for Health and Care Excellence, 2014. [viewed 27/04/18]. Available from: https://www.nice.org.uk/guidance/ipg483/resources/inserting-a-magnetic-bead-band-for-faecal-incontinence-pdf-474842514373
NIH NIDDK. (2013). Smoking and the Digestive System. [online] National Institute of Diabetes and Digestive and Kidney Diseases, 2013. [viewed 27/04/18]. Available from: https://www.niddk.nih.gov/health-information/digestive-diseases/smoking-digestive-system
Norfolk and Norwich University Hospitals. (2017). Anal Sphincter Repair. [online] NHS Trust, 2017. [viewed 27/04/18]. Available from: http://www.nnuh.nhs.uk/publication/anterior-sphincter-repair/
Raivio, P. (2001). Faecal Incontinence Protocol. [online] Verity Medical, 2001. [viewed 26/04/18]. Available from: https://www.stressnomore.co.uk/downloads/instructions/81710-IFUS_5.pdf