Faecal incontinence (bowel incontinence)
Bowel incontinence, also called faecal (fecal) incontinence or anal leakage, is the inability to control the bowels, resulting in the unplanned loss of liquid stool (diarrhoea), solid faeces or flatulence (wind). It is different to having sudden-onset (short-term) diarrhoea .
It is difficult to know how common bowel incontinence is, but various research studies suggest that about 10% of adults soil their underwear regularly (British Medical Journal 2010;340:1350-5).
What you can do about bowel (faecal) incontinence
Firstly, special thanks to everyone who has provided feedback about how to get on with your life when you have this problem. Some of your suggestions are mentioned here. As one person wrote, ‘At the end of the day, it's a bodily reaction which is out of your control. If you mess, just laugh it off, clean up, and get on with your day. It doesn't mean you are dirty, stupid or a kid, you're just unfortunate for having such a time- consuming illness’.
Think about what and when you eat. You may have noticed that eating stimulates the urge to pass faeces, so changing the timing of your meals and their size may help to reduce the possibility of anal leakage. For some people, eating more fibre to bulk up the faeces helps (British Medical Journal 2010;340:1350-5). Look at our constipation section for information. Other people find that this makes the problem worse, and that a low-fibre diet is better for them.
Pads, wipes and underwear. It makes sense to wear a protective pad, or to carry spare underwear and wet wipes. It may also be useful to carry a spare long-sleeved top to wrap around your hips if you do have an accident. Don’t let the fear of faecal leakage prevent you from swimming. A special undergarment is available, worn next to the skin under your swimsuit (see Useful contacts).
Sphincter exercises. There are exercises that will strengthen the anal muscles. Look at the website of St Mark’s Hospital UK, listed in the Useful contacts. It has a leaflet (Anal Sphincter Exercises for Leakage) explaining how to do these exercises.
Bowel training. It may help if you try to empty your bowels at a specific time every day, for example first thing in the morning or after your evening meal. Over time this will make your bowel movements more predictable and give you greater control over when you need to go to the toilet. For sudden urges, wait as long as you can before sitting down to empty your bowels, gradually increasing the amount of time you wait. You should soon find it easier to hold on for longer.
Loperamide is a medication that prevents the bowel muscle squeezing too strongly, and makes the faeces more solid. It can be bought from pharmacies. It would not be advisable to take it all the time, but it is very useful for occasions where you might be particularly worried about leakage from the bowel.
For a summary of treatment options for bowel (faecal) incontinence, go to:
PatientPictures.com: Fecal incontinence treatment options
What your doctor can do about bowel (faecal) incontinence
Your doctor will try to work out what the cause is. There are many reasons why people become incontinent and very often the cause is a combination of factors. Working out when and how the incontinence occurs can help to narrow down the causes. Therefore, before seeing the doctor, you may wish to keep a bowel diary for a week, listing when you are troubled by the leakage. The UK’s Bladder and Bowel Foundation has a good example of a bowel diary
that you can download.
The doctor will examine you. This will involve a rectal examination to feel the sphincter muscles and look for a rectocoele
(rectal prolapse – in women, this is a bulging of the rectum into the back wall of the vagina; in men [extremely rare] the protrusion is usually backwards rather than forwards). Further tests may include colonoscopy, CT scan, pressure testing of the sphincter (anorectal physiology), ultrasound scan of the sphincter muscle or a dye (contrast) test, also called a proctogram, which shows how you pass faeces.
The treatment for incontinence depends on the cause and therefore should be discussed with your doctor before trying any method.
Conservative measures. Often, bowel incontinence will respond to simple measures such as making the stool firmer (see 'What you can do' above) and by changes in medication. Physiotherapy in the form of biofeedback can also be very effective in some cases. Rectal irrigation can also be effective in certain cases. This involves the insertion of a tube into the rectum to wash the faeces out with water. This procedure usually needs careful training to perform it safely, so it must be undertaken with close medical supervision. The majority of people will respond to conservative measures and will not need any further treatment.
Injectable bulking agents. If the anal muscles are weak, injections of ‘bulking agents’ into the wall of the anus may help, but these injections have to be done by a specialist doctor and it is uncertain how effective the treatment is (British Journal of Surgery 2005;92:521–7).
Neuromodulation. For major incontinence, percutaneous tibial nerve stimulation (PTNS) or sacral nerve stimulation is a possibility. PTNS is a non-surgical technique in which a small needle electrode is inserted into the tibial nerve just above the ankle, and impulses travel to the nerves that control bowel function. The procedure is quite new and there is limited information about how well it works. Sacral nerve stimulation involves insertion of electrodes into the lower back, attached to a pulse generator, and is an expensive procedure. A surgical operation is a last resort and may not be successful.
For more information on percutaneous tibial nerve stimulation, go to:
Sphincter surgery. If tests on your sphincter muscles (usually performed after referral to hospital) show there is a gap (defect) in the muscles, then surgery is sometimes recommended in the form of a sphincter repair. This can be quite a difficult decision to make; success of this operation depends on many factors. Therefore, a specialist will discuss the operation with you carefully before any decisions are made.
Causes of bowel (faecal) incontinence
Diet is the first thing to check. Anything that makes the consistency of the faeces more runny, such as a heavy intake of beer, will make it more difficult for you to hold them in. Rhubarb, figs, prunes and plums all contain a natural laxative, and excessive doses of vitamins and minerals (vitamin C, magnesium, calcium) can worsen leakage of faeces. In some people, caffeine loosens the faeces, so it might be a good idea to reduce your intake of coffee or other caffeinated products (e.g. energy drinks, cola).
Olestra, used in some ‘slimming’ foods, has gained unwelcome publicity for this reason. It is an artificial mixture of fats, none of which can be digested or absorbed. Instead, it goes straight along the gut and is passed out at the other end. This means that the faeces are runny and slippery with fat, and soiled underwear can result. Some snack foods (e.g. some crisps) contain olestra, but the amount in the snacks is too small to cause a problem.
Some chewing gums contain sorbitol as a sugar-free sweetener. Sorbitol has a laxative effect, so chewing large amounts of sugar-free gum will make your faeces runny (British Medical Journal 2008;336:96–7).
Anything which makes you pass more wind makes leakage more likely. This is because the anus has to relax to let the wind
out, and some faecal material may be propelled out at the same time. Beans, cabbage, sprouts and some spices (such as chilli) commonly cause this problem.
Irritable bowel syndrome
is the other common cause. In irritable bowel syndrome
(also known as IBS), the bowel muscle squeezes strongly, so that it may be difficult to hold the faeces in. If you have abdominal pain as well as leakage of faeces, then IBS is a strong possibility. The pain of IBS can occur anywhere in the abdomen, but is usually felt low down on the right or left side. Passing wind or opening the bowels often relieves it. People with IBS often have to rush to the toilet, and some leakage is common. There is also often a ‘morning rush’ – the bowels have to be opened urgently several times on rising and after breakfast.
For more information on irritable bowel syndrome, go to:
Childbirth. After having a baby, more than 1 in 10 women finds that she has difficulty in controlling wind or faecal leakage. It is most likely if you were an older mother (over 35 years of age) or had a large baby or are overweight. The reason may be that the anal muscle is damaged by a tear, or by the episiotomy cut made during childbirth. Damage to the pudendal nerve can also occur during childbirth, and result in incontinence. The problem is likely to improve somewhat, but if you first noticed faecal incontinence after having a baby, do see your doctor – a surgical operation to repair the damage often gives good results even if you have had the problem for years.
It is quite common to have both faecal leakage and leakage of urine
. A study of women with incontinence of urine found that almost 1 in 4 also had some leakage of faeces (Obstetrics and Gynecology
2002;100:719–23). The connection is that both are related to childbirth, especially if the baby was large.
Faecal leakage is also quite common in older people, because the anal muscle becomes weaker with age. This is something that you should definitely discuss with your doctor, because a lot can be done to help. The real reason may be constipation
– if you have hard faeces in the lower bowel, some watery faeces can leak round them and be difficult to control. Doctors are very familiar with this problem (called ‘overflow incontinence’) and should know how to deal with it.
makes loose faeces more likely (American Journal of Gastroenterology
2004;99:1807–14). So losing weight
Some medications make the faeces looser and therefore more difficult to hold in. Check that you are not taking a laxative from habit. If you are taking an indigestion remedy, check that it does not contain magnesium trisilicate, because this can cause diarrhoea. Misoprostol (a medication for stomach and duodenal ulcers that is sometimes prescribed for elderly people), calcium channel blockers (for blood pressure), nitrates (for angina), sildenafil (for erection problems
) and SSRIs (for depression) are other possible culprits (British Medical Journal
2010;340:1350-5). If you are taking any of these drugs, do not just stop them; discuss the problem with your doctor.
Orlistat (Xenical, Alli) is a diet pill that works by blocking the enzymes that digest fat. This means that the fat cannot be absorbed from the gut. With the correct dose, a third of the fat that you eat is blocked, and is excreted in the faeces instead of ending up as part of your spare tyre. By the time it reaches the lower part of the gut, this extra fat has the consistency of light machine oil. As a result, it can cause oily anal leakage, and the problem gets worse with the more fat that you eat. To stop it happening, you have to eat less than 70 g of fat a day.
can prevent the anus closing properly, so leakage can occur.
Rectocoele (rectal prolapse).
can empty after a bowel movement, whilst you are walking. This can produce a small amount of faeces in your underwear which you may not always realize is happening. This can often be helped by simple measures and you should see your own doctor about it.
Written by: Dr Andrew Ramwell
Edited by: Dr Andrew Ramwell
Monday, May 12th 2014
Useful contacts for Faecal incontinence (bowel incontinence)
Click to see all the contacts that you may find useful in relation to faecal incontinence
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