Often shrouded in a sense of stigma or embarrassment, fecal incontinence is more common than many people realize. This Q&A with Dr. Abby Linzay aims to break the silence by providing insight into the causes of bowel leakage, discussing the treatments available and answering the questions you’re too embarrassed to ask.
Understanding Fecal Incontinence
What is fecal incontinence?
Fecal incontinence (FI) is the inappropriate loss of stool: an “accident.” There are varying degrees of fecal incontinence. Mild symptoms may occur when someone sees stool unexpectedly when wiping. More severe incontinence can present as full accidents requiring a change of clothes.
Are small skid marks considered fecal incontinence?
Oftentimes, yes. Occasionally (in children), a poor job of wiping after a bowel movement can cause “skid marks.” This is not true incontinence. If these occur spontaneously in adults, that is true fecal incontinence.
What causes fecal incontinence?
Fecal incontinence has many causes. Most often, FI is due to weakness of the sphincter muscle, which can occur naturally with age or even with lifelong constipation. However, other common causes are damage to the sphincter muscle from injuries or surgery, neurologic diseases, and inflammatory bowel disease. It can also occur after childbirth, especially if there was injury of the sphincter muscle due to tearing during vaginal birth. Prolapsing internal hemorrhoids or rectal prolapse can also cause passage of stool unexpectedly. A common reversible cause of incontinence is “overflow incontinence.” This occurs when severe constipation prevents the colon from absorbing any additional water. The excess water or watery stool is passed uncontrollably, and it often seems like the patient is experiencing diarrhea. An appropriate bowel regimen (usually utilizing laxatives) will typically resolve this issue.
What is passive fecal incontinence?
Passive incontinence occurs when stool slips out of the rectum without any warning or inciting event.
Is fecal incontinence a normal part of aging?
No. Just because something is common does not make it normal. It is true that incontinence increases with increasing age due to various factors, such as lower muscle tone or underlying diseases that can predispose to fecal incontinence. However, incontinence is never normal or expected.
Is fecal incontinence neurological?
It can be neurological. In certain patients with diseases of the spinal cord or injuries to the spinal cord or the nerves that control the rectum, patients may not have the ability to control their bowels.
Treatment Options For Fecal Incontinence
What happens if you ignore symptoms of fecal incontinence?
While some patients may have spontaneous resolution of their symptoms, oftentimes symptoms will either remain the same or even worsen over time.
What are treatment options for fecal incontinence?
There is no cure for fecal incontinence. There are many options for treatment of fecal incontinence that include conservative and aggressive therapies. Conservative measures include fiber therapy, dietary modification, anti-diarrheal therapy and lifestyle modifications (such as timed toileting). Pelvic floor physical therapy (particularly with biofeedback) is another low-risk option for treatment of FI. More invasive options include injection of bulking agents into the rectum, tibial nerve stimulation or sacral nerve stimulation (such as InterStim™). In some cases, repairing the sphincter muscle with a surgery known as sphincteroplasty is also indicated. As a last resort, a diverting colostomy can be performed to control where stool exits the body.
Can fecal incontinence be improved through diet changes like adding more fiber?
Yes. A conservative approach (such as increasing dietary fiber or supplementing with psyllium husk-based fiber therapy) is almost always the first recommended step in the treatment of fecal incontinence.
What is InterStim™?
InterStim™ is a discrete surgical implant that helps treat (not cure) fecal incontinence. It’s placed by a surgeon under the skin just above the buttock. InterStim™ is typically a two-part procedure. The first part, performed by me, involves placement of temporary leads while under sedation. These are left in place for seven days, and we monitor the patient’s response. If the temporary placement is successful, a referral to a surgeon is made to place the permanent implant. This is battery-powered. The battery lasts for 10 to 15 years.
How does InterStim™ work?
InterStim™ sends an impulse to the sacral nerve, which controls the tone of the anal sphincter muscle tone. The device helps the muscle maintain its normal tone to prevent stool leakage.
Can you go through metal detectors with InterStim™?
Yes.
Can you feel the electrical pulses with InterStim™?
No. After a device settings change, patients may feel a temporary pressure or “fluttering,” but these sensations are temporary. The body will get used to the stimulation.
Does fecal incontinence require surgery?
If InterStim™ is chosen as the preferred treatment strategy and the test phase is successful, it does require a minor surgery to place the permanent implant. A colostomy or sphincteroplasty (rebuilding the sphincter muscle) are also surgical options for incontinence treatment. All of the aforementioned procedures would be performed by a colorectal surgeon.
Will I end up with a colostomy bag?
A colostomy is a “last resort” treatment for fecal incontinence. Most often, patients achieve improvement or resolution of their symptoms with more conservative measures before this is needed.
Will I ever be 100% again or just have fewer accidents?
Patients have varying degrees of success depending on the treatment option pursued. Patients who choose colostomy will never have accidents again. Those who choose conservative therapies like dietary fiber and pelvic floor physical therapy may continue to have occasional accidents but less frequently.
Fecal Incontinence Statistics
What are some stats of fecal incontinence?
Because fecal incontinence is often underreported, true estimates are hard to come by. Literature reports that between 4.5% to 9.5% of all adults experience fecal incontinence. It is more common in adults older than the age of 60. It is more common in women (9.1%) than men (7.4%), likely attributed to pregnancy and childbirth.
Is fecal incontinence common after childbirth?
About 1 in 4 women may experience fecal incontinence after childbirth within the first six months.
Will fecal incontinence go away on its own after childbirth?
A review of the literature shows that fecal incontinence will resolve spontaneously in most patients after childbirth. This can be improved with conservative measures like timed toileting, increasing fiber and pelvic floor physical therapy. Risk factors include older age at time of delivery, episiotomy or significant perineal tearing during vaginal birth. If symptoms are still present at nine months postpartum, this is suggestive that symptoms may persist beyond the postpartum period.
When do you need to see a doctor for fecal incontinence after childbirth?
Any time fecal incontinence occurs after childbirth, you should address this with your doctor. Your gynecologist, primary care provider or gastroenterologist can provide insight and a referral for further evaluation or treatment if necessary.
Talking To Your Doctor About Fecal Incontinence
How do I talk to my doctor about fecal incontinence?
It’s best to have a direct approach to your doctor, so we can determine how best to help you. Saying “I’m having stool accidents” is the best place to start.
What terminology should you use when talking about fecal incontinence?
No specific terminology is needed. However, the most helpful information you can provide to us is the following:
- When did it start? Did something like an injury, surgery or childbirth precede your symptoms?
- How long has it been going on?
- Have you tried anything to fix it? How successful was it?
Which doctor should you talk to about fecal incontinence?
You can speak to your primary care provider or your gastroenterologist about fecal incontinence.
What tests will be performed to test for fecal incontinence?
The most important workup for fecal incontinence includes a thorough history and a good physical exam, including a rectal exam. This provides most of the information we need to move forward with treatment. There are tests that can provide helpful adjunct information. They include anorectal manometry to evaluate the pelvic floor muscles, endoanal ultrasound to evaluate the anal sphincters, and/or EMG to test the nerves of the rectum and pelvic floor. The need for these is determined by your doctor after your history and physical exam.
What are doctors thinking when you tell them you have a leaky bowel?
I can speak to what I’m thinking when a patient complains of fecal incontinence. My first thought is “I know this is having a huge impact on your quality of life, your physical health and your emotional health. Let’s find a way to improve this and get your life back to normal.”
Answering the questions you have but are too afraid to ask.
Can other people smell me?
Most accidents are small, and others cannot tell that someone has had an accident.
Will I ever be able to be intimate again?
Yes. Sometimes, simple lifestyle adjustments like timed toileting can decrease the risk of accidentally passing gas or stool during intimacy.
Can anal sex cause fecal incontinence?
Anoreceptive sex or use of objects in the anus (such as sex toys) is a known risk factor for fecal incontinence. These cause stretching and weakening of the sphincter muscle, sometimes to the point of incontinence.
Should I wear adult diapers?
Adult diapers can be helpful to prevent soiling of clothes, especially if accidents are frequent or occurring at night.
Could my leaky bowel be a result of late-stage cancer?
If it’s going to occur, fecal incontinence (FI) usually happens as a side effect of cancer treatment rather than the initial presentation of cancer. FI as the sole presentation of cancer is extremely rare.
Is fecal incontinence an early symptom of ALS or MS?
No. Fecal incontinence usually occurs in later stages of neurologic disease, such as ALS or MS. It is very often due to overflow incontinence from severe constipation. Although true fecal incontinence is also observed in this population, it is almost never the initial presentation.
Is it normal that I can’t feel the sensation of needing to go to the bathroom?
This is a common symptom. It’s most often observed in patients with a history of chronic constipation.
How do I clean myself properly and avoid diaper rash?
The most important thing to prevent diaper rash is to ensure that the skin is clean and dry. Also, I recommend being gentle with the skin around the anus. It’s delicate, so wiping excessively or too hard can also cause irritation to that area. Moist wipes or a bidet may assist with gently and thoroughly cleaning the area. However, you always want to ensure that you are dry before leaving the restroom to avoid any trapped moisture.
What do I do if I have an accident in public?
If accidents are frequent or unpredictable, I recommend being aware of nearby bathrooms and carrying a change of clothes in the event of an accident. Adult diapers are also helpful in preventing clothes from being soiled.
Are there plugs that you can use to prevent leaks?
No. Physical obstruction of the anus is not a good treatment for fecal incontinence, and it can lead to worsening of symptoms.
What tips do you have to prevent an accident while traveling?
Lifestyle modifications like timed toileting (making a conscious effort to visit a restroom after meals or before travel time even in the absence of feeling like you need to have a bowel movement) can be helpful. If patients suffer from diarrhea, Imodium® prior to traveling is also usually effective at preventing accidents while traveling. Trying to maintain a healthy, balanced diet and continuing fiber therapy will also help.
What diapers do you recommend? Do you prescribe diapers?
Almost all adult diapers are suitable for patients experiencing incontinence. These are available “over the counter,” and they do not require a prescription.
At GastroIntestinal Specialists (GIS), we have extensive experience helping patients manage bowel leakage. If you are suffering from fecal incontinence, you aren’t alone. More importantly, you don’t have to just live with it.
The team at GastroIntestinal Specialists, A.M.C., treats multiple conditions and diseases of the gastrointestinal (GI) tract. Our board-certified physicians have more than 325 years of combined experience in providing quality care you can trust. To schedule an appointment, call (318) 631-9121 or visit gis.md.