Fecal Incontinence Symptoms & Causes

Introduction

Fecal incontinence is an underdiagnosed problem and becomes an untreated condition because of the social stigma. As a result, individuals find it difficult to discuss the symptoms with their care provider.  Individuals with fecal incontinence cannot sense rectal fullness or control the elimination of gas and stool. Therefore, fecal incontinence negatively affects the quality of life, impacts emotional health, and causes social isolation. Fecal incontinence is caused by multiple complex factors that impair normal continence to prevent the leakage of stool. Many of the causes are treatable. A thorough history and physical examination can identify the cause and guide the management of fecal incontinence.

 

Assessment

  • Bowel diary: An individual would complete a three to five-day bowel diary of all timed defecation events and fecal or gas incontinence episodes. The diary also includes a stool description based on a stool form scale, estimated amount, any abnormalities (blood or mucous), straining or splinting (inserting fingers in the vagina or pushing on the perineum). In addition, dietary and medications should be recorded.
  • Medical history: In reviewing the medical history, previous and current treatments for constipation, and history of a colonoscopy.
  • Abdominal Examination: Palpate for findings such as distention, tenderness, masses, retained stool in sigmoid, and bowel sounds.
  • An anorectal exam: The exam includes assessing for the presence of retained stool, hemorrhoids, pain, rectal prolapse, masses, resting tone of the internal and external sphincter squeeze. 
  • Perineal skin: Assess skin integrity for incontinence-associated dermatitis.

Advanced Testing

  • Anorectal manometry: The test evaluates the sphincter function and measures resting and squeeze pressures. 
  • Balloon distention measures rectal distention and sensation of rectal urge.
  • Colonic Transit Study: This test evaluates the transit time of the entire colon.
  • Colonoscopy:  This test provides preventative screening or detection of colon cancer.
  • Defecography: The test consists of barium placed in the rectum to visualize the anorectum and pelvic floor during defecation.
  • Electromyography: The test evaluates the neurologic function of the pelvic floor muscles.
  • Endoanal ultrasonography detects structural problems with the internal and external sphincters.

Classification of Fecal Incontinence

  • Passive incontinence: An individual is unaware of rectal leakage and the sensation to have a bowel movement. 
  • Urge Incontinence: An individual has a sudden urge to have a bowel movement, resulting in an incontinent episode.
  • Flatus Incontinence: An individual is unable to hold gas.
  • Transient Incontinence: Refers to a short-term. Management is focused on an underlying cause, such as acute diarrhea.
  • Chronic Incontinence: Refers to a long-term persistent or recurring.

Causes of Fecal Incontinence

The cause of fecal assessment is based on the evaluation and testing. The reason can be acute or chronic.

 

Obstruction

  • Tumors: Tumors cause a partial or complete obstruction. A partial obstruction changes the stool’s shape to a flat ribbon-like form.
  • Colon Motility Disorders: Motility disorders involve pelvic floor muscles, colon, rectal prolapse, or anal sphincter muscles. These disorders cause constipation that is difficult to manage.
  • Constipation: Chronic constipation and hemorrhoids can contribute to fecal impaction, and watery stool can leak around the impaction, causing incontinent overflow diarrhea.

Diarrhea

  • Fecal infection can be caused by viral (Norovirus or foodborne) and bacterial (E-Coli and C-diff) infections.
  • Functional motility disorders:  (irritable bowel disorders or inflammatory bowel disease) 
  • Malabsorption problems with tube feedings, fat malabsorption, and short bowel syndrome.

Impaired Continence Mechanism

  • Trauma to continence mechanisms: Injury to the anal sphincter may occur during childbirth. Surgical complications (rectal, prostate, gynecological) may damage the nerves and muscles. Congenital disabilities (myelomeningocele) can cause nerve damage and paralysis to the intestines or anal sphincter. 
  • Chronic laxative abuse: Laxative overuse can lead to constipation and damage the colon and nerves.

Impaired Sensory Awareness

  • Spinal cord injuries may also cause nerve damage. 
  • Long term pelvic pain
  • Neuropathy (radiation, diabetes chemotherapy, multiple sclerosis)
  • Cognitive impairment (dementia, psychological disorders)

Conservative Management

  • Dietary: Dietary changes can aid in the change of consistency of stool. Insoluble fiber increases the bulk and water in the stool to stimulate peristalsis and increases sensory awareness by increased rectal distention. In addition to dietary changes, it is also essential to drink an adequate amount of water to prevent dehydration.
  • Respond promptly to the urge of the need to have a bowel movement.
  • Bowel Retraining: Timed training 20-30 minutes after breakfast.
  • Regular exercise to promote bowel motility
  • Pelvic floor exercises: The exercises are the same for urinary incontinence.
  • Biofeedback: This neuromuscular training can improve pelvic floor muscles and sensory awareness. 
  • Devices: Anal plug is inserted in the rectum for 12-hour use. May become displaced with a bowel movement or cause rectal bleeding. A vaginal bowel control device has an inflatable balloon to prevent stool passage. Fecal pads are butterfly-shaped and indicated for small volume leakage.

Medication Management

  • Anti-diarrheal: Decreases muscle in the bowel to decrease the movement of stool through the bowel. 
  • Stool softener laxative: Softens the stool for easier passage through the bowel.
  • Osmotic laxative: Draws water into the bowel to soften stool.
  • Stimulant laxative: Increases muscle movement in the bowel to push the stool through the bowel. 

Invasive and Surgical Options

  • Anal Canal Bulking: Bulking agents are injected to aid in the function of the internal anal sphincter with seepage spoilage.
  • Sacral Nerve stimulation:  Therapy is indicated for individuals with internal and external sphincter injuries who failed conservative therapy.
  • Anal Sphincteroplast: Correction of Pelvic floor defects

Conclusion

Fecal incontinence is a common problem and is treatable. However, it is often undertreated because most do not seek help due to embarrassment and not knowing most causes are treatable. A full review of the medical and surgical history, medications, and dietary diary guide the provider to find the causes of incontinence and provide appropriate treatment.

 

Future Reading and References

Brown, Heidi W. MD, MAS; Dyer, Keisha Y. MD; Rogers, Rebecca G. MD Management of Fecal Incontinence, Obstetrics & Gynecology: October 2020 – Volume 136 – Issue 4 – p 811-822

doi: 10.1097/AOG.0000000000004054 

 

Forootan, M., Bagheri, N., & Darvishi, M. (2018). Chronic constipation: A review of literature. Medicine, 97(20), e10631. https://doi.org/10.1097/MD.0000000000010631

 

Kamal, N., Motwani, K., Wellington, J., Wong, U., & Cross, R. K. (2021). Fecal Incontinence in Inflammatory Bowel Disease. Crohn’s & colitis 360, 3(2), otab013. https://doi.org/10.1093/crocol/otab013

 

Lin, Yu-Hua; Chen, Hsin-Pao; Liu, Kuang-Wen Fecal Incontinence and Quality of Life in Adults With Rectal Cancer After Lower Anterior Resection, Journal of Wound, Ostomy and Continence Nursing: July/August 2015 – Volume 42 – Issue 4 – p 395-400 doi: 10.1097/WON.0000000000000135 

 

Norton, Christine; Dibley, Lesley Help-Seeking for Fecal Incontinence in People With Inflammatory Bowel Disease, Journal of Wound, Ostomy and Continence Nursing: November/December 2013 – Volume 40 – Issue 6 – p 631-638 doi: 10.1097/WON.0b013e3182a9a8b5 

Saldana Ruiz, N., & Kaiser, A. M. (2017). Fecal incontinence – Challenges and solutions. World journal of gastroenterology, 23(1), 11–24. https://doi.org/10.3748/wjg.v23.i1.11

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