Last Updated: April 4, 2013
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 incontinence.
Fecal incontinence, often enshrouded in social stigma, 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 percent.
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
Causes and Symptoms
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 nervous
- Chronic laxative abuse:Long-term, frequent reliance on
laxatives to maintain regularity may cause fecal incontinence.
- 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 the anus.
- 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.
multiple sclerosis, various forms of
diabetes, 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
- Rectal inelasticity:Scarring from radiation or surgery can
harden rectal walls, diminishing their ability to hold stool.
- 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 control.
- Surgery:Virtually any operation involving the rectum and anus,
including hemorrhoid removals, risks damaging the sphincter
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 small 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 infections. The doctor may touch the skin in these
areas using a probe, testing for the normal anal response to such
stimulation. A digital exam may then follow, using a gloved,
lubricated finger to check anal strength and rectal walls.
A number of ways can be used to determine the exact cause of
your loved one's fecal incontinence:
- Anal manometrytests anal strength and rectal response by the
insertion of a tube and inflatable balloon into the rectum through
the anus. Rectal sensation is tested by delicately inflating and
deflating the balloon. According to Rao, manometry is the most
accurate and effective tool to determine the cause and severity of
- Anorectal ultrasonographyevaluates the structure of the
sphincter with a wand-like instrument inserted into the anus and
rectum. The wand emits sound waves used to create an image of the
- 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 electrodes.
- Flexible sigmoidoscopy/colonoscopyuses a long, slender,
flexible tube with a video camera attached to explore the last two
feet of the colon for abnormalities.
Treatment and 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 patient.
- Medication:Occasionally doctors recommend medication to treat
fecal incontinence. Medications may include:
- 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
- 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 incontinence.
- 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
- 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
- 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
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