What is Fecal Incontinence?
Fecal incontinence is the inability to control bowel movements, resulting in the unintentional leakage of stool from the rectum.
Stool may leak unexpectedly, with or without awareness.
Leakage can range from occasional soiling to the loss of an entire bowel movement.
Fecal incontinence can affect people of any age, but it is more common in women and becomes more prevalent with age.
What Causes Fecal Incontinence?
Fecal incontinence can have several underlying causes. Problems affecting the bowel, rectum, anal sphincter muscles, pelvic floor, or nerves can make it difficult to control bowel movements and prevent stool leakage.
Common causes and risk factors include:
- Frequent diarrhea or chronic constipation, which can interfere with normal bowel control
- Damage or weakness of the anal sphincter or pelvic floor muscles, including damage related to childbirth, surgery, or injury
- Nerve damage affecting the nerves that control the rectum and anal sphincter
- Older age, as muscle strength, nerve function, and rectal sensitivity may change over time
- Reduced ability of the rectum to stretch and store stool
- Reduced rectal storage capacity, which can make it harder to hold stool until an appropriate time
- Rectal prolapse, when the rectum protrudes downward through the anus
- Rectocele, when the rectum bulges into the vagina
- Chronic constipation, particularly when stool becomes impacted or the rectum is stretched over time
- Frequent or excessive use of laxatives, which can contribute to diarrhea and changes in bowel habits
- Radiation therapy, particularly when the pelvic area is treated
- Certain neurological conditions or congenital abnormalities affecting bowel control
- Inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis
What are the Symptoms?
Symptoms of fecal incontinence can range from occasional stool leakage to a complete inability to control bowel movements.
Common symptoms include:
- Fecal urgency: A sudden or strong need to have a bowel movement, with difficulty reaching the bathroom in time
- Stool leakage when passing gas: Small amounts of stool may leak unintentionally when passing gas
- Stool leakage during physical activity: Leakage may occur with exercise, lifting, bending, coughing, sneezing, or other everyday activities
- Stool found in underwear: Small amounts of stool or staining may be noticed in the underwear, sometimes without realizing leakage has occurred
- Complete loss of bowel control: An inability to control a bowel movement, resulting in the involuntary passage of stool
How is Fecal Incontinence Diagnosed?
Your healthcare provider may recommend several tests to determine the underlying cause of fecal incontinence, bowel leakage, or difficulty controlling bowel movements. Testing can assess the anal sphincter muscles, pelvic floor, nerves, rectum, and surrounding pelvic structures.
- Physical and Rectal Examination: A physical exam, including a digital rectal examination, evaluates the strength and function of the anal sphincter muscles and pelvic floor. It can also help identify abnormalities, rectal prolapse, hemorrhoids, or other conditions that may contribute to bowel control problems
- Anal Manometry: A small, flexible tube with pressure sensors is gently inserted into the anus and rectum to measure muscle pressure and function. This test evaluates anal sphincter strength, sensation, and coordination and can help identify problems with the muscles responsible for controlling bowel movements
- Endoanal (Endoluminal) Ultrasound: A small ultrasound probe is inserted into the anus and rectum to create detailed images of the anal sphincter muscles. It can identify structural damage, thinning, or tears in the sphincter muscles and assess the surrounding tissues
- Pudendal Nerve Terminal Motor Latency (PNTML) Test: This test evaluates the function of the pudendal nerves, which play an important role in controlling the anal sphincter. Abnormal nerve function may contribute to fecal incontinence or reduced bowel control
- Anal Electromyography (EMG): EMG measures the electrical activity of the muscles and nerves involved in bowel control. It can help identify nerve or muscle damage and evaluate how well the anal sphincter and pelvic floor muscles coordinate during contraction and relaxation
- Flexible Sigmoidoscopy/Proctosigmoidoscopy: A thin, flexible scope is inserted through the anus to examine the rectum and lower portion of the colon. This test can help identify inflammation, bleeding, polyps, tumors, or other abnormalities that may contribute to bowel symptoms
- Proctography/Defecography: During this imaging test, contrast material is placed into the rectum, and X-ray images are taken while the patient relaxes and attempts to empty the bowel. Defecography can show how the rectum and pelvic floor function during a bowel movement and may identify problems such as rectocele, rectal prolapse, or difficulty emptying the rectum
- Magnetic Resonance Imaging (MRI): An MRI can provide detailed images of the pelvic organs, pelvic floor muscles, anal sphincters, rectum, and surrounding tissues. Depending on the type of MRI performed, it may help identify structural abnormalities, muscle damage, prolapse, or other causes of bowel control problems
How Is Fecal Incontinence Treated?
Treatment for fecal incontinence (bowel leakage) depends on the underlying cause and may include dietary changes, bowel retraining, pelvic floor therapy, medications, or surgery. Many people benefit from a combination of treatments designed to improve stool consistency, strengthen the pelvic floor and anal sphincter, and improve control over bowel movements.
- Dietary Changes: Adjusting your diet can help make stools more formed and easier to control. Your healthcare provider or dietitian may recommend reducing foods that contribute to loose stools, diarrhea, gas, or urgency, such as beans, cabbage-family vegetables, dairy products, dried fruit, spicy foods, and artificial sweeteners. Keeping a food and symptom diary can help identify individual triggers
- Bowel Retraining and Biofeedback: Bowel retraining helps establish a more predictable bowel movement routine and may improve your ability to recognize and respond to the urge to have a bowel movement. Biofeedback therapy, provided by a trained healthcare professional, can teach you how to correctly contract and relax the anal sphincter and pelvic floor muscles and improve muscle coordination and bowel control
- Pelvic Floor Muscle Exercises: Exercises may help strengthen the muscles that support bowel control. A pelvic floor physiotherapist can assess your muscle function and teach you exercises tailored to your needs
- Medications: Medications may be recommended depending on whether diarrhea, loose stools, constipation, or another bowel disorder is contributing to fecal incontinence. Anti-diarrheal medications may slow intestinal movement and help make stools firmer. In some cases, fibre supplements or bulk-forming laxatives may be recommended to improve stool consistency and make bowel movements more predictable
Surgical and Procedural Treatments
When dietary changes, medications, pelvic floor therapy, and other conservative treatments do not provide adequate relief, procedures or surgery for fecal incontinence may be considered.
- Sphincteroplasty (Anal Sphincter Repair): This surgery repairs a damaged or weakened anal sphincter, including injuries that may occur during childbirth. The surgeon identifies the damaged portion of the sphincter, separates the injured muscle edges from surrounding tissue, and brings the muscle ends back together in an overlapping fashion. This can restore muscle strength and improve anal closure
- Rectocele or Rectal Prolapse Repair: Surgery may be recommended when rectal prolapse or a rectocele is contributing to fecal incontinence or difficulty emptying the bowel. Repairing the underlying structural problem may improve bowel control and reduce leakage
- Sacral Neuromodulation (Sacral Nerve Stimulation): Sacral neuromodulation uses a small implanted device to deliver mild electrical stimulation to the sacral nerves, which help regulate the muscles and nerves involved in bowel control. A small generator is typically implanted under the skin, while a lead is positioned near the sacral nerves. This treatment can improve communication between the nerves, pelvic floor, and anal sphincter and may reduce episodes of fecal incontinence
- Artificial Bowel Sphincter: In selected cases, an artificial anal sphincter may be considered when the natural sphincter is severely damaged and other treatments have not been successful. The device uses an inflatable cuff placed around the anal canal to help maintain continence. When it is time to have a bowel movement, a control mechanism is used to temporarily deflate the cuff, allowing stool to pass
- Dynamic Graciloplasty: This procedure uses muscle from the inner thigh (the gracilis muscle) to create a new muscular support around the anal canal. The muscle is repositioned around the anal sphincter to provide additional muscle tone and improve bowel control. This procedure is now used less frequently because other treatment options are available
- Colostomy (Bowel Diversion): A colostomy creates an opening (stoma) in the abdomen through which stool is diverted into a specially designed collection bag. A colostomy may be considered for severe fecal incontinence that has not responded to other treatments or when other medical or surgical options are not appropriate. Although sometimes described as a last-resort treatment, it can provide significant improvement in quality of life for some people with severe bowel control problems
