Brief overview
- Causes: Deteriorating sphincter and pelvic floor muscles, triggered, among other things, by increasing age, illness (e.g. stroke) or injury (e.g. perineal tear after childbirth).
- Treatment: The doctor treats fecal incontinence depending on the cause. Remedies include medication, biofeedback and physiotherapy, a change in diet or anal tampons. In severe cases, surgery is necessary.
- Description: In fecal incontinence, affected individuals lose the ability to retain their bowel contents as well as bowel gases.
- Diagnosis: discussion with the physician (e.g., about bowel behavior), physical examinations of the sphincter and rectum (e.g., colonoscopy, ultrasound examination, anal sphincter manometry, defecography).
- Course: Prognosis varies widely and depends on the cause as well as the age of the affected individual. In many cases, the quality of life can be significantly improved by appropriate therapies.
What are the causes of fecal incontinence?
Bowel evacuation is a complex process involving several areas of the intestine. The so-called continence organ “anorectum” (sphincter) closes the anus. It makes it possible to retain or expel bowel movements and intestinal gases in a controlled manner (continence). The continence organ consists of the rectum (= last section of the intestine), as a reservoir for the stool, and the sphincter apparatus (= sphincter), which surrounds the anal canal.
If one or both of the components are damaged in the course of life due to diseases, malformations or injuries, fecal incontinence may occur. Rarely, bowel incontinence is congenital, for example due to malformations.
The most important causes of fecal incontinence at a glance:
Weak sphincter and pelvic floor muscles in old age.
Perineal tear after childbirth
Women are often affected by fecal incontinence after vaginal birth. In this case, the sphincter muscle (perineal tear) tears, often unnoticed, during the pushing contractions, which later leads to discomfort. Bowel incontinence can also occur as a result of anal surgery in which the sphincter muscle is injured.
Rectal prolapse
Rectal prolapse (rectal prolapse) also causes fecal incontinence under certain circumstances. This is when the rectum shifts from its original position and protrudes from the anus (often during solid bowel movements). Most often, advanced hemorrhoids (grade 3 to 4) trigger rectal prolapse.
Neurological diseases
Another possible trigger is discomfort in the spine or when the pelvic nerves are damaged after vaginal delivery. Likewise, pregnancy in some cases causes the muscles of the pelvic floor to weaken. Especially in the period shortly before birth, some women then experience an unwanted discharge of flatulence or stool.
Diarrhea
In diarrheal diseases, thin stools, even in otherwise healthy people, can overtax the sphincter muscle and cause affected individuals to be unable to retain stool. Causes of diarrhea are often infections, food poisoning, food intolerances (e.g., lactose intolerance), and less commonly chronic bowel diseases (e.g., Crohn’s disease or ulcerative colitis).
Constipation
The watery stool is usually difficult to control and as a result comes out in droplets. In addition, people with constipation often push too hard to empty the bowel. This can lead to the sphincter muscle being overstretched or injured, which further promotes fecal incontinence.
Bowel constriction due to tumor or surgery
If the bowel is narrowed by a tumor or if the rectum has been surgically reduced in size (e.g., after removal of a tumor or anal fistulas), fecal incontinence may subsequently occur.
Obesity
Severe overweight (obesity) promotes weak pelvic floor muscles and thus, among other things, fecal incontinence.
Medication
In some cases, certain medications lead to fecal incontinence. These include laxatives (e.g. kerosene), antidepressants and drugs for Parkinson’s disease.
Mental disorders
What can be done about fecal incontinence?
The doctor treats fecal incontinence depending on the cause. Initially, he usually relies on non-surgical (conservative) therapies. These include medication, pelvic floor muscle training, biofeedback or a change in diet. In most cases, these measures already bring good results.
If underlying diseases, such as a chronic inflammatory bowel disease, are the cause of the symptoms, the doctor first treats these in order to subsequently repair damage to the sphincter muscle.
In severe cases of fecal incontinence or if non-surgical measures do not bring the desired success, surgery is necessary.
Pelvic floor training
Exercises for fecal incontinence
To strengthen your pelvic floor and sphincter muscles, specific exercises help. In this way, you can improve your wind and stool control and prevent fecal incontinence.
Exercise in supine position
- Lie on your back on a straight surface.
- Stretch your legs out parallel and tense your buttocks along with your sphincter (squeeze!).
- Hold the tension for three seconds as you exhale, and then relax the muscles as you inhale.
- Repeat the exercise once with your legs extended and crossed, and once with your legs up (knees bent, bottoms of feet on the floor).
Exercise while sitting
- Sit down on a chair.
- Tilt your upper body slightly forward.
- Place both legs next to each other and perform the first exercise (supine exercise) while sitting.
- Now press both heels against each other, and at the same time push the knees apart.
Exercise in prone position
- Lie on a straight surface in the prone position.
- Press your heels together and at the same time push your knees apart.
- Tighten your gluteal muscles while doing this.
Exercise while standing
- Stand up straight.
- Tense your sphincter muscle along with your gluteal muscles.
- Hold the tension for three seconds as you exhale, and then relax the muscles as you inhale.
- Repeat the exercise as you walk.
Exercise in everyday life
- In everyday life (e.g. waiting at a red light, brushing your teeth in the morning, driving, at the office) try to tense your buttocks and sphincter for a few seconds. Hold the tension as long as possible.
It is best to do these exercises regularly (about ten repetitions per exercise twice a day).
Diet
Swelling foods, such as psyllium soaked in water, also increase stool volume, which normalizes stool consistency. Rice, a grated apple or mashed bananas likewise help the intestines regulate bowel movements.
On the other hand, people with fecal incontinence should avoid foods that irritate the bowel, such as coffee, alcohol and flatulent foods (e.g. beans, cabbage, carbonated drinks).
A stool diary can help you develop a better sense of which foods and habits promote your continence or make symptoms worse.
Proper bowel habits
When going to the bathroom, it’s important to pay attention to proper bowel habits. Keep the following in mind:
- Only go to the toilet when you have an urge to defecate.
- Do not push too hard during bowel movements.
- Do not sit on the toilet for too long (no more than three minutes, no reading the newspaper).
Aids
Biofeedback
In order to better perceive the pelvic floor and the sphincter tension itself, the use of biofeedback can help as a supplement. To do this, the doctor places a small balloon in the anal canal via a probe, which the patient has to squeeze with his sphincter muscles.
A device indicates via visual or acoustic signals when the patient squeezes the ball. It also indicates how strong the contraction of the anal muscles is. The biofeedback training follows an individually defined exercise plan, which is worked out by the doctor. Usually, only a few sessions (about six to ten) are needed to reactivate the pelvic floor, and sufferers continue to exercise (without a device) at home afterwards.
Electrostimulation
In the case of inflammation of the rectum, the use of biofeedback and electrostimulation is not recommended, as this further irritates the intestinal wall.
Medication
Various medications can be used to treat fecal incontinence. Depending on the desired effect, the physician may prescribe either laxatives (laxatives) or drugs that inhibit bowel activity (motility inhibitors).
To prevent a surprise discharge of stool, he prescribes laxatives that stimulate the colon to expel stool. In addition, mild laxative suppositories or enemas (clysters) may be used to specifically empty the bowel at a desired time.
Motility inhibitors such as the active ingredient loperamide cause the transport of food through the intestine to be slowed down. The stool thickens and the patient has to go to the toilet less frequently.
Surgery
Surgery in the pelvic floor area should ideally be performed by a specialized physician (proctologist) in a surgical center specializing in this area.
Surgery on the sphincter muscle
The most common method used for fecal incontinence is surgery, in which the doctor restores the sphincter muscle as much as possible. To do this, the doctor sews the sphincter muscle back together after injuries or tears. He performs the operation through the anus, that is, without an abdominal incision, and therefore it is not very stressful for the patient.
If the sphincter is severely damaged, the doctor often replaces it with a body-derived implant (usually a muscle from the thigh), also called gracilisplasty. In some cases, the doctor uses a non-body artificial sphincter or a plastic anal band.
Bowel pacemaker (sacral nerve stimulation)
The method is particularly suitable for people whose fecal incontinence is caused by a neurological disorder. The procedure under anesthesia lasts about 40 minutes, and usually requires a short inpatient stay in the hospital.
Prolapse surgery
In the case of rectal prolapse, the doctor fixes the rectum to the sacrum in the small pelvis with the help of a plastic net. The doctor usually performs this operation during a laparoscopy through the abdominal wall using an endoscope. This is also a minor procedure that does not require a large abdominal incision.
The procedure is usually followed by a hospital stay of four to five days.
Injections with “bulking agents
However, the effect of bulking agents often lasts only a short time and must be repeated. Since allergic reactions to the substances are also possible, this therapy is only performed in exceptional cases of fecal incontinence.
Artificial bowel outlet
If all treatment options fail, in rare cases the doctor creates an artificial bowel outlet (stoma), which he or she may then operate on again. In this case, the doctor connects part of the colon to the abdominal wall. This creates an opening to which a bag is attached for defecation. However, this procedure should only take place after careful consideration.
For lasting treatment, non-surgical measures are usually necessary for support after surgery.
What is fecal incontinence?
Fecal incontinence is not a disease in its own right, but occurs as a symptom of various diseases. Depending on its severity, it can be divided into three degrees of severity:
Grade 1: The underwear is frequently soiled and bowel gases escape uncontrollably.
Grade 2: The underwear is frequently soiled, intestinal gases escape uncontrollably and the affected person loses liquid stool.
Grade 3: The affected person no longer has control over when and where he or she passes liquid and solid stool and allows intestinal gases to escape.
Who is particularly affected?
In general, fecal incontinence can affect people of any age group. About one to three percent of the population worldwide suffer from fecal incontinence. In Germany, about 800,000 people are affected. The number of older people affected is much higher than that of younger people.
Psychological stress with fecal incontinence
People with fecal incontinence usually have a very high level of suffering because the time of fecal loss is unpredictable. This is often associated with shame and great psychological stress for those affected. Due to their fear of getting into an unpleasant situation in public, people with fecal incontinence often withdraw.
They prefer to stay at home, turn down invitations, do not go to events or restaurants, and do not share their experiences with those around them (e.g. family, friends) out of shame. They usually suffer severely from social isolation.
People with fecal incontinence often do not dare to discuss their problem with their doctor. However, help from the doctor and a variety of therapies as well as numerous aids are certainly available. In many cases, fecal incontinence is easily treatable, which usually allows sufferers to lead a normal everyday life despite bowel incontinence.
How does the doctor make the diagnosis?
At the first prolonged difficulties with stool control (e.g., when flatulence escapes involuntarily), it is important to see a doctor early on.
Which doctor to consult for diagnosis varies depending on the cause. This can be either the family doctor, a gynecologist, a urologist or a rectal specialist (proctologist). The following applies: the sooner you contact a doctor, the sooner he or she can help you and, in the best case, remedy the symptoms.
Talk with the doctor
First of all, the doctor will have a detailed conversation with the patient and take a medical history. Among other things, he asks questions about the symptoms and bowel movements.
Doctors recommend keeping a diary of toilet habits about two weeks before the doctor’s appointment:
- How many times a day do you have bowel movements?
- @ How often do you have to hurry to get to the toilet on time?
- How often does stool come off uncontrollably without you feeling it?
- Do you wear pads/diapers?
- Are your underwear or pads soiled?
- Does your fecal incontinence prevent you from performing normal daily activities, such as leaving your home or going shopping?
- What is the consistency of your stool? Predominantly firm, soft, liquid?
A frank discussion with your doctor is the first step in finding the cause of your symptoms and goes a long way toward finding the right treatment.
The path to clarification often takes a long time. Many sufferers refuse to talk about the subject out of shame and fear. But don’t be afraid to confide in your doctor. He is there to help you and improve your quality of life with appropriate treatment.
Physical examination
To assess the sphincter and rectum, the doctor gently palpates them. Among other things, he determines the degree of tension of the sphincter muscle at rest and when it is consciously contracted. If necessary, the doctor uses the palpation to determine whether polyps or tumors are present.
Further examinations
The doctor then performs a rectoscopy (examination of the rectum) and colonoscopy (examination of the colon). This allows him to rule out tumors as a (rare) cause of fecal incontinence.
This is followed by further examinations to assess the function of the sphincter muscle. With so-called sphincter manometry (anorectal manometry), the doctor measures the pressure values in the anal canal using a small probe (measuring catheter). An anal examination with ultrasound (endosonography) also provides the doctor with information on whether there are any injuries to the sphincter muscle, such as those that occur after childbirth or surgery.
If necessary, the doctor will use imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI) to produce cross-sectional images of the sphincter and pelvic floor.
Is fecal incontinence curable?
The prognosis for fecal incontinence varies from person to person. Both the cause and the age of the affected person influence the course. However, appropriate therapies often alleviate the symptoms and significantly improve the quality of life. However, it is not always possible to completely restore bowel control.
How can fecal incontinence be prevented?
It is not possible to specifically prevent fecal incontinence in all cases. However, there are some measures you can take to significantly reduce your risk:
- Exercise regularly.
- Strengthen your pelvic floor muscles (e.g. through pelvic floor training or specific exercises).
- Avoid overg
- Refrain from eating flatulent foods (e.g. beans, cabbage, carbonated drinks).
- Drink enough (at least two liters of fluid per day).
- Make sure you have regular bowel movements.
