Fecal incontinence or anal incontinence, in technical terms anorectal incontinence, is the, in all age groups occurring, inability to control bowel movements or bowel gases and leads to spontaneous, involuntary bowel evacuation. This condition, which can occur in three degrees of severity, is associated with high psychosocial distress and requires extensive therapeutic intervention.
What is fecal incontinence?
Anorectal incontinence is divided into three degrees of severity:
In the first degree, the mild stage, bowel movements pass uncontrollably. Affected individuals in the second, moderate, degree are unable to hold thin bowel contents, and in the third, severe, stage, there is a complete loss of control over bowel evacuation; even solid stool can no longer be retained. The classification into severity levels neglects important aspects of fecal incontinence such as the frequency of uncontrolled defecation and social problems of the affected person. To date, no precise classification has been made that takes these aspects into account. Fecal incontinence affects approximately three percent of the German population of all ages, with a clear increase in incidence in old age and in women. A related childhood condition is encopresis, the repeated, voluntary or involuntary defecation beginning at age 4.
Causes
Fecal incontinence has numerous causative factors, several of which must come together to trigger the condition. If only one mechanism controlling bowel movements fails, the body has adequate compensatory mechanisms to prevent fecal incontinence. The most common causes are:
Damage to the sphincter muscle at the anus, for example, due to perineal rupture, after surgical procedures, for example, fistula or hemorrhoid operations, and due to “slippage” of the anal canal or rectum from their natural position. Pelvic floor weakness may also be among the causes. This is caused by severe obesity, muscle and connective tissue weakness, and can occur after childbirth. Bowel diseases, such as Crohn’s disease, can also trigger anorectal incontinence. Fecal incontinence can also occur with nerve damage from strokes, major pelvic surgery, herniated discs, paraplegia or medications. A rare cause is psychological problems such as traumatic experiences and psychosis. Abuse of laxatives can also cause fecal incontinence. Last, patients with dementia are also frequently affected by this burden.
Symptoms, complaints, and signs
The main symptom of fecal incontinence is an inability to voluntarily retain intestinal gas as well as stool in the rectum. Characteristic signs of the condition include repeated involuntary loss of stool (“fecal accidents”), feces-soiled undergarments, a general inability to control the discharge of gas, and uncontrolled opening of the bowel. Depending on the specific form of fecal incontinence, the condition can manifest itself in different ways. In the case of sensory fecal incontinence, sufferers do not notice the urge to defecate. Those with urge incontinence notice the urge to defecate, but are unable to control it and must hurry to make it to a toilet in time. The consistency of the stool is often the decisive factor. Around half of those affected are only unable to hold soft and mushy stools. In one third, this inability occurs even when the stool is solid. In many cases, fecal incontinence occurs in combination with constipation. Those affected also often suffer from severe abdominal pain, bloating and bowel movements that can take a long time. Rarely, overflow incontinence also occurs, in which sufferers have constipation but still have diarrhea that pushes past the hard stool.
Diagnosis and course
The diagnosis of fecal incontinence is made in a detailed anamnesis on the onset of symptoms, accompanying circumstances and existing diseases by a proctologist. This is followed by rectal examination of the rectum to determine any changes. If further examination is required, the proctologist will arrange for proctoscopy of the anal canal or rectoscopy of the rectum. The reflection of the entire intestine, the colonoscopy, may also be necessary, but is rarely used due to the high expense.During the endoscopies, the physician can take tissue samples from the intestinal mucosa and/or swabs from the anal mucosa and evaluate them microscopically. Sphincter function can be determined electronically during a pressure measurement. Imaging procedures may be useful, including X-ray examination of the rectum under contrast media.
Complications
Fecal incontinence leads to complications primarily at the psychological level. For example, the involuntary leakage of bowel movements and feces often causes affected individuals to isolate themselves socially. They no longer participate in activities and avoid social events. At the same time, many sufferers conceal their condition from their environment or even their doctor, which, in the case of organic causes, can mean that any possible treatment is no longer effective after a certain point. In the presence of hemorrhoids, colitis or other infections and abscesses in the corresponding area as the cause of fecal incontinence, a carryover can lead to an expansion of the inflammation and can even reach the complete destruction of the tissue. Surgical measures for the treatment of fecal incontinence include the usual risks of complications during or after surgery. In addition, measures aimed at surgically altering the anus (using the patient’s own tissue or a “STARR” implant, for example) can lead to pain and inflammation of the anus or bowel. Bleeding may also occur. Other complications associated with fecal incontinence arise from the variety of conditions that may be considered as causes. The relevant medical condition should be considered here.
When should you go to the doctor?
In the case of persistent or recurrent disorders of bowel emptying, a check-up visit to a doctor should be made. If constipation, diarrhea or blood in the stool occurs, action is needed. If bowel movements cannot be regulated voluntarily, there is a disorder that should be investigated and treated. A diagnosis is necessary so that an individualized treatment plan can be developed. If spontaneous defecation occurs during the day or during night sleep, a visit to the doctor is advisable. If the causes lie in an incorrect diet, the taking of medication or if the affected person suffers from a strong stress experience, the observations should be discussed with a doctor. Abnormalities and peculiarities that take place immediately before sudden bowel evacuation should be documented and presented to the physician. A decrease in well-being as well as an increase in mental stress are signs of health impairment. If the symptoms persist for several weeks or months, the affected person needs a medical examination. Reduced sexual activity, interpersonal problems or withdrawal behavior on the part of the affected person are indications of irregularities. There may be physical illnesses that need to be clarified. Flatulence or unpleasant body odors are other signs that should be investigated. If severe abdominal pain or abdominal discomfort occurs, a visit to the doctor is also necessary.
Treatment and therapy
The cause of anorectal incontinence determines its therapy. A healthy diet with regulation of bowel movements is also advised to regain control through regularity of bowel movements. At this point, the administration of laxatives at a certain time and toilet training are also effective. This is carried out over several weeks with the aid of a stool diary and is intended to accustom the bowel and the patient to regular, controllable bowel emptying. If the sphincter muscle is unable to function properly, surgery may be necessary. Either the patient is given an artificial or endogenous sphincter replacement or an artificial anus is inserted. Modern sacral nerve stimulation is promising for neuronal causes. Here, the sphincter is stimulated by a pacemaker in such a way that it contracts and retains the stool, and voiding only occurs at appropriate times. Therapy also includes incontinence care with aids designed to prevent soiling of underwear and clothing. According to individual criteria and conditions, for example, diapers, incontinence pants, anal tampons or stool bags are used for immobile patients.
Prevention
There are few preventive measures against fecal incontinence.Pelvic floor exercises are not only useful during and after pregnancy and childbirth, they are generally recommended regardless of gender. On the one hand, it has a preventive effect, but on the other hand, it can also address functional causes of fecal incontinence.
Aftercare
Fecal incontinence can be effectively countered with pelvic floor exercises – via pelvic floor exercises, the muscles in the anal as well as pelvic area can be specifically strengthened. Pelvic floor training shows good results especially in patients with connective tissue weakness, but also in women after several births. Vaginal cones can be used to train the pelvic floor muscles. A change in toilet habits, called toilet training, can also provide relief – with specific behavioral therapy techniques, for example, introducing regular times when going to the toilet. In addition, biofeedback is an effective measure in the fight against fecal incontinence: Here, the affected person learns to consciously perceive his sphincter tension as well as to control it accordingly. For this purpose, a small balloon is inserted into the anal canal. This causes the patient to tense the sphincter muscle. A signal indicates when a certain pinching pressure has been reached. Biofeedback training is based on an individually designed exercise plan and helps many patients. Electrostimulation is another method: Here, a weak current flow, a stimulation current, helps to stimulate the sphincter muscle – the latter is passively tensed in this way. However, noticeable effects only occur after a few weeks. This means that patients need stamina. And last but not least, in many cases a change in diet, for example an increased intake of fiber-rich foods, can help. This can increase stool volume and normalize stool consistency.
What you can do yourself
For fecal incontinence, pelvic floor exercises are recommended. Daily training of the pelvic floor muscles strengthens the connective tissue and and muscles. At best, this improves the ability to retain stool. Good “toilet training” also includes establishing regular toilet times. If the patient knows when they feel the urge, they can target their daily routine accordingly. With biofeedback, the patient consciously perceives his sphincter tension. The individually determined exercise plan can be carried out by the patient at home. Electrostimulation of the sphincter function is also possible. Here, a weak current flow stimulates the tension of the sphincter muscle. Immediately after an operation on the sphincter muscle, rest and protection are the order of the day. Operations such as colostomy or prolapse surgery place a greater strain on the body and especially the gastrointestinal tract. The patient should adhere to the prescribed diet and not subject the sphincter muscle to unnecessary stress until the symptoms are completely cured. Lastly, patients must comply with the measures prescribed by the doctor and carefully observe the symptoms. The more comprehensively the condition is studied, the more specifically the patient can also take action against it himself.
