Anal (Fecal) Incontinence

Do you leak stool from the rectum unexpectedly?  Do you have problem controlling your gas? Do you experience difficulty holding your stool once you feel the urge to have a bowel movement? If so, you are likely suffering from Anal/ Fecal Incontinence. Anal incontinence is defined as the involuntary or accidental loss of flatus, liquid or solid stool that is a social or hygienic problem.

The problem is more common than you may think. Current estimates state that more than 5.5 million Americans have anal incontinence. Several studies have placed the prevalence of anal incontinence as high as 14% in the general population. A more troubling statistic indicates that as many as 50% of women with urinary incontinence also have fecal incontinence. The following is perhaps the most troubling statistic of all: according to a 1982 study published in The Lancet, 50% of women with fecal incontinence never report it unless specifically asked by their physician.

Patients should understand that fecal incontinence affects women, men and children; it affects the young, the middle-aged and the elderly.  It does not discriminate based on race or socioeconomic status, and its effects can be devastating.  Individuals with fecal incontinence may feel embarrassed or humiliated.  Some patients with fecal incontinence refuse to leave the house and withdraw from society due to fear and anxiety of having an episode of incontinence in public.

Many women feel that fecal incontinence is simply a normal part of aging. This couldn’t be further from the truth. There are several treatment strategies to improve and even cure fecal incontinence, but unless your provider knows you are suffering from the problem, very little can be done. Please, if you suffer from this devastating problem, speak with your provider today about treatment options.

Fecal incontinence can have several causes:

• Diarrhea
• Fecal impaction or chronic constipation
• Irritable bowel syndrome
• Rectal prolapse
• Fistulae
• Damage to the anal sphincter complex (obstetric trauma)
• Damage to the nerves controlling the sphincter/rectum (again, mainly obstetric trauma)
• Neurologic disorders such as stroke, dementia, multiple sclerosis, spinal/nerve injuries

Diarrhea

Diarrhea, or loose stool, occurs as the fecal material moves through the gastrointestinal (GI) system at a much quicker rate. Liquid stools are more difficult to control than solid stools.Think of the differences in trying to hold a banana in your hand versus holding a liquid substance. If the diarrhea and gut motility is strong enough, people who normally do not have fecal incontinence can still leak stool. Individuals with diarrhea-related fecal incontinence are generally more easily cured of their incontinence than those with anatomic or neurologic defects.

Fecal Impaction/Constipation

This is one of the more common causes of fecal incontinence. Most people with fecal incontinence aren’t leaking hard, constipated stools, but when large amounts of hardened stool become lodged in the rectum, looser, more watery stools can work around the impaction and leak from the anus. Sometimes, if the impaction or constipation is severe enough, the anus can actually be held open, making leakage occur more easily.

Irritable Bowel Syndrome

Irritable Bowel Syndrome (IBS) is a disorder leading to pain and changes in stool habits, and can sometimes lead to fecal incontinence. IBS is diagnosed in individuals who have experienced abdominal pain for at least 12 weeks out of the last 12 months and who experience 2 of the following:

• Pain relieved with defecation
• Onset associated with a change in stool frequency
• Onset associated with a change in stool consistency

Those with IBS may also experience the following, although they are not required for diagnosis:

• Abnormal stool frequency (more than 3 per day or less than 3 per week)
• Passage of mucus in more than 25% of defecations
• Bloating or abdominal distention in more than 25% of days

Rectal Prolapse

Rectal prolapse occurs when the rectal mucosa (or rectal tissue) falls down and sticks through the anal opening. In doing so, it is physically holding the external anal sphincter open and can cause incontinence. The severity of rectal prolapse ranges from mild which may be treated at home to severe, which may require surgical intervention.

If you think you may have rectal prolapse, contact your physician immediately, as an exam will be necessary.

GI Tract Fistulae (Rectovaginal Fistulae)

A rectovaginal fistula is a medical condition where there is a abnormal connection between the rectum and vagina.  If the opening between the rectum and vagina is wide enough, fecal material can leak through the hole into the vagina, leading to fecal incontinence. Please see the section on Rectovaginal Fistula for further information.

Muscle Damage

Childbirth’s effects on continence can be profound. Damage to a series of muscles in the female pelvis, including the puborectalis, internal and external anal sphincter muscles, can alter the body’s ability to remain continent. Childbirth injuries, including episiotomies, can cause a direct tear into or through the sphincter muscles. With the sphincters playing an important role in both involuntary and voluntary continence, disruption of one or both of the sphincters can lead to episode of stool leakage. Many times, despite a sphincter injury, younger women can maintain continence as other muscles and stronger pelvic tone can compensate for an injury. Many times, we will see women in their 60s who are having their first episodes of fecal incontinence as their muscle tone diminishes and they begin to lose their ability to compensate for a ruptured sphincter muscle. The risk of injury increases in women who have undergone operative vaginal deliveries, particularly forceps deliveries, and in those who have had certain types of hemorrhoid resections.

Nerve Damage

Damage to the nerves that control aspects of the pelvic floor can also lead to incontinence. Nerves in the pelvis may be stretched during childbirth, or other pelvic injuries (including those sustained in motor vehicle collisions) may occur. Nerves that control the sphincter muscles, as well as those nerves that sense rectal filling and tolerance can be damaged, leading to either improperly functioning muscles or to a neurogenic pelvic floor causing overflow fecal incontinence. Neurologic problems such as those found with stroke, diabetes and multiple sclerosis can mimic traumatic nerve injuries, also leading to incontinent episodes.

Anal Manometry

Anal manometry is a test that measures the resting and squeeze pressures of the internal and external anal sphincter muscles. It also measures sensation and tolerance in the rectum, and gives specific feedback about the neural reflexes between the brain and bowel (the RAIR, or rectoanal inhibitory reflex test). This test, lasting approximately 5-10 minutes, involves insertion of a small flexible tube with a tiny balloon attached at the tip, into the rectum. The tube is about the size of a thermometer. During the test, our providers will be asking you to relax your pelvic floor and then to squeeze your pelvic floor as if you are attempting to hold in gas. The pressure measurements will be taken at different locations in the rectum to give an overall average of resting and squeeze pressures.

Endoanal Ultrasound

Endoanal ultrasound uses sound waves to generate an image of soft tissues. Our providers will use the ultrasound to establish if there are specific anatomic defects, or tears, in the anal sphincter muscles. The endoanal ultrasound uses a small probe about the size of your finger, which is inserted into the rectum to obtain the images. The procedure only takes 1-2 minutes to complete and should not be painful.