Last Updated: April 30, 2015
In 1985, while giving birth to her son, Nancy Norton received a
fourth-degree laceration of her external sphincter muscle. Since
that injury, Norton has managed her own fecal incontinence-the
involuntary leaking of stool.
"Within an instant my life had changed dramatically, and I had
no idea how I was going to get through life with fecal
incontinence," recalls Norton, who in 1991 founded the
International Foundation for Functional Gastrointestinal Disorders
(IFFGD) to address the lack of public information on fecal
Fecal incontinence affects up to 17 million people in the United
States, according to the IFFGD. Obstetrical injuries such as
Norton's are the number one cause and result in about 60 percent of
cases, according to Dr. Satish Rao, professor of gastroenterology
and hepatology at University of Iowa Health Care. Fecal
incontinence is the second most common reason for committing the
elderly to nursing homes. About one
third of elderly under institutional care have it, and some
estimates go as high as 47%.
Fecal Incontinence Defined
Fecal incontinence is the inability to control bowel movements.
The condition can range from an occasional leakage of stool while
passing gas to a complete loss of bowel control.
"Between a third and half of the patients have impaired
awareness of stool in the rectum," says Rao, "what we call an
impaired rectal sensation. If you're not aware that the stool is
there, by the time you know it's too late and the stool leaks
Healthy bowel function is controlled by rectal sensation, rectal
accommodation, and anal sphincter muscles. A malfunction in one or
more of these things may result in fecal incontinence. As feces
move from the last part of the large intestine, called the sigmoid
colon, they enter the rectum. As rectal walls stretch, they signal
the need to have a bowel movement. The two anal sphincter
muscles-an involuntary inner and a voluntary outer-hold the feces
in the rectum until a toilet can be reached, at which time they
relax and release the stool. People who suffer from fecal
incontinence may not sense a full rectum and, if so, may not be
able to hold feces because of damaged nerves and sphincter
Fecal Incontinence Causes
Fecal incontinence is commonly the result of muscle or nerve
injuries that accelerate the natural aging process of pelvic
muscles and tissues in the elderly. It is important to note that it
is not an inevitable consequence of aging, but that it may indicate
a more serious condition, such as:
Disease: Those suffering from late-stage Alzheimer's
commonly experience fecal incontinence because of its effect on the
- Chronic Laxative Abuse: Long-term, frequent
reliance on laxatives to maintain regularity may cause fecal
- Constipation: Constipation is one of the more
common causes of fecal incontinence, especially in the elderly.
When stools become hardened in the rectum-"impacted"-the looser,
watery stool must move around the drier mass and often leaks from
- Diarrhea: Especially in cases of sphincter
muscle and nerve damage, the loose stools of diarrhea are more
challenging to retain in the rectum.
- Muscle Damage: Damage to sphincter muscles can
occur during rectal surgery or in childbirth in which episiotomy or
forceps are used. In cases of damaged sphincter muscles, fecal
incontinence may not show up until later in life. "[Women] have
healthier tissues that compensate for lack of muscle function and
so on," says Rao. "A woman who would normally become incontinent at
age 80, once she has an obstetrical injury may become incontinent
at age 45."
- Nerve Damage: Childbirth may cause nerve
damage and limit a woman's rectal sensation. Prolonged, severe
straining over a lifetime may also damage nerves.
- Neurological Conditions: Many diseases besides
Alzheimer's that affect the nervous system may also cause fecal
incontinence. Examples are multiple
sclerosis, various forms of dementia,
spinal cord tumors, and spinal injuries.
- Rectal Cancer: Cancer of the rectum affects
the lining of the rectal walls and can lead to abnormal tissue
growth that eventually harms the muscle walls or nerves that signal
the need for bowel movements.
- Rectal inelasticity: Scarring from radiation
or surgery can harden rectal walls, diminishing their ability to
- Rectal Prolapse: A condition usually caused by
severe and chronic straining to move the bowels, it occurs when the
rectum drops through the anus, or through the vagina in women.
- Stress: The stress of being in an unknown
environment may contribute to an older person's lack of bowel
- Surgery: Virtually any operation involving the
rectum and anus, including hemorrhoid removals, risks damaging the
Diagnosing Fecal Incontinence
The diagnosis of fecal incontinence begins with a visit to a
physician, who may refer the patient to a specialist. The physician
typically asks about the patient's current and past living
environments, including bowel habits. A physical examination may
follow, in which the anus and perineum (the area between the anus
and genitals) are examined for abnormalities such as hemorrhoids or
A number of ways can be used to determine the exact cause of
your loved one's fecal incontinence:
- Anal Manometry: Involves inserting a tube and
inflatable balloon into the rectum through the anus to test rectal
sensation, strength and response.
- Anorectal Ultrasonography: Evaluates the
structure of the sphincter with a wand-like instrument inserted
into the anus and rectum.
- Defecography (or Proctography): Uses X-rays to
view the shape and position of the rectum during defecation.
- Anal Electromyography (EMG): Tests the nerve
function in the muscles around the anus by using tiny needle
- Flexible Sigmoidoscopy/Colonoscopy: Uses a
long, slender, flexible tube with a video camera attached to
explore the last two feet of the colon for abnormalities.
Treatment & Management
According to Norton, fecal incontinence is not "owned" by any
single group of health practitioners. "It tends to be something
that really falls through the cracks," says Norton. "Unfortunately,
in this country, we don't have continence advisers like in other
countries. You have to do a lot of searching to find someone to
direct your care, other than sending you home with an absorbent
Yet as time passes and the stigma of fecal incontinence
decreases-especially in settings that provide elderly
assistance-the options for successfully and fully treating the
condition have continued to grow. Today, your loved one can choose
from many different treatment options:
- Biofeedback: Often used in conjunction with
bowel training-the regular scheduling of toilet visits-biofeedback
training is one of the most effective treatments for fecal
incontinence, according to Rao. "The treatment aims to improve anal
sphincter function, particularly the voluntary ability to squeeze
and maintain the squeeze," he says. According to Rao, biofeedback
training helps coordinate and strengthen "rectal-anal coordination"
through the use of an inserted probe that measures sphincter
contraction and muscle pressure, information that is relayed to the
- Medication: Occasionally doctors recommend
medication to treat fecal incontinence. Medications may
- Anti-diarrheal drugsthat prevent watery stools, such as
Imodium®, Lomotil® (diphenoxylate and
atropine), Lotronex® (alosetron), and
Pepto-Bismol®. In addition, drugs such as
Nulev® (hyoscyamine sulfate), which treats cramping, and
Questran® (cholestyramine), which treats high
cholesterol, may also prove effective.
- Laxativessuch as milk of magnesia that relieve temporary
- Stool softenerssuch as Colace and Dulcolax that prevent stool
impaction, which causes constipation.
- Exercise: Kegel exercises, or pelvic floor
exercises, strengthen the muscles of the anus. In a Kegel exercise,
the pelvic, buttocks, and anal muscles are contracted and held for
a slow count of five. A series of thirty of these three times daily
generally improves or resolves incontinence.
- Surgery: Surgery that replaces or repairs
sphincter muscles is the most invasive treatment for fecal
incontinence. For the elderly, whose muscle tissues have lost their
resilience, it can be the only option.
- Sphincteroplastyrepairs damaged muscle by separating it from
healthy muscle, then sewing it back in overlapping fashion to
strengthen and tighten the sphincter.
- Sphincter replacementuses an inflatable cuff implanted around
the anal canal to replace the sphincter function. It is deflated to
defecate and automatically reinflates.
- Sphincter repair, also called agracilismuscle transplant, wraps
the sphincter with inner-thigh muscle to restore tone.
- Colostomyis a last-resort procedure that diverts stool through
an opening in the abdomen and is collected in a special bag.
- Diet: What your loved one eats and drinks
affects stool consistency. Drinking enough water and eating fruits,
vegetables, and whole grains that are high in fiber softens stools
and prevents diarrhea and constipation that may lead to
- Hygiene: Keeping skin clean of fecal matter
reduces the odors and irritations common to fecal incontinence.
Skin creams and gels provide a moisture barrier that prevents
direct contact with fecal matter. Absorbent products temporarily
isolate fecal matter from skin.
- Toileting: Allowing an appropriate amount of
time for toileting your loved one is essential. The average amount
of time for a bowel movement is nine minutes, yet in most nursing
homes that provide elderly assistance in toileting, only five
minutes are allowed, according to Norton. She suggests that is the
reason why so many nursing home residents enter without fecal
incontinence, but eventually suffer from it.
- Experimental Treatments: In the last few
years, several new treatments for fecal incontinence have arrived
and are still being tested:
- Phenylephrine gelis being tested as an anal-muscle toner.
- Injectable bulking agentsare used by some surgeons to increase
muscle mass and improve sensation.
- Sacral nerve stimulationelectrically stimulates sacral nerves
from a matchstick-size device implanted at the base of the
Fecal Incontinence Support
In addition to offering your loved one practical support such as
elderly assistance with regular toileting, providing loose cotton
clothing, and moisture-proofing furniture, it is important to
remember that he or she needs social and emotional support as well.
Fecal incontinence is a socially and psychologically devastating
condition. People who have it are often too humiliated and severely
embarrassed by it to discuss it openly. Fortunately, there are
several organizations that can help you and your loved one in
dealing with fecal incontinence. Most of the information they
provide is free.
International Foundation for Functional Gastrointestinal
National Association for Continence
The Simon Foundation for Continence
American College of Gastroenterology
National Institute of Diabetes & Digestive & Kidney