Symptoms & Care
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 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 out.”
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 muscles.
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:
- Alzheimer’s Disease: Those suffering from late-stage Alzheimer’s commonly experience fecal incontinence because of its effect on the nervous system.
- 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. Examples are multiple sclerosis, various forms of dementia, 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 movements.
- 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 muscles.
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 infections.
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 electrodes.
- 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 product.”
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 constipation.
- 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 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 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 spine.
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 Disorders
National Association for Continence
The Simon Foundation for Continence
American College of Gastroenterology
National Institute of Diabetes & Digestive & Kidney Diseases
Update: January 2018