Faecal Incontinence

Introduction

Faecal incontinence is the term describing the inability to control the bowels. It is a devastating condition that can result in depression, social isolation, laundry costs and skin breakdown. Faecal incontinence is surprisingly common and affects women, men and children. Although it is common, people are embarrassed to bring up the issue with their health care provider and suffer in silence, constantly worried about odour and leakage. Professionals often forget to ask about faecal incontinence and patients can suffer for years without help. It is important to know that the condition can be effectively treated or managed.

Contributing Factors

There are multiple underlying causes of faecal incontinence. The most common include:

• Childbirth. The muscles of the anal sphincter can be stretched or even torn during vaginal birth. There can be nerve damage as well due to stretching of the nerve or a combination of direct muscle damage and nerve trauma.This usually occurs when the birth is difficult or when instruments are used to facilitate the delivery.
• Anal sphincter damage. Injury can also be caused by surgery such as that for treatment of cancer of the bowel or pelvic organs, or, inadvertently, during operations to remove haemorrhoids (piles).
• Congenital malformations. Conditions such as spina bifida or anorectal malformations that affect the nerves.
• Chronic constipation. Constant straining during defecation can gradually stretch pelvic floor and rectal muscles so that they no longer control the passage of stool or gas. Further, when patients suffer impaction of stool, liquid material above the stool blockage leaks around and escapes through the defective sphincter. Such impaction may eventually cause leakage from the bowel called “overflow diarrhoea”. Blockage can be caused by tumours, as well as stool.
• Anal conditions. Haemorrhoids, rectal prolapse, or rectocele may be associated with leakage.
• Diarrhoea. Loose or watery stool may be associated with faecal urgency and the abnormal consistency contributes further to loss of control. Individuals with chronic bowel disorders or those who have had bypass surgeries for obesity often experience diarrhoea on a regular basis, making faecal control a recurring challenge.
• Neurological disorders. Individuals with neurological conditions may have difficulty with sensation or with muscular control, or both. Spinal cord injury, multiple sclerosis, brain injury and spina bifida are among the many conditions that are associated with faecal incontinence.
• Diabetes. Nerve damage from diabetes, termed diabetic neuropathy, is a common cause of anal sphincter dysfunction.
• Aging. Elderly adults, particularly those in nursing homes, often become constipated due to poor oral intake, medications, disease and immobility. Almost half of people in nursing homes suffer from faecal incontinence.
• Other factors. Other extrinsic or intrinsic factors that may impair faecal control include anxiety, medications, diet, alcohol and caffeine consumption and use of restraints as well as bathroom accessibility for people with disabilities and impaired mobility.

Presentation

Faecal incontinence can present as inability to control the passage of gas, liquid stool or solid stool. Based on the frequency and quantity. it can be further quantified as mild moderate and severe.

Faecal incontinence can be also be classified as “urgent” or “passive”.

• Urgency faecal incontinence occurs when the urge to have a bowel movement is very strong and access to a bathroom is needed urgently. The anal sphincter muscles are not strong enough to hold the stool back, so leakage occurs before toileting can occur. As noted above, constipation or diarrhoeal states as well as bowel inflammation from radiation, Crohn’s disease, or ulcerative colitis can cause urgency facal incontinence.
• Passive incontinence is usually associated with, neurological dysfunction, hyposensation of the anal canal being the predominant sign. Impacted stool combined with anal sphincter weakness results in stool leakage, usually without any warning or sensation.

Assessment

The first step is to determine the factors contributing to faecal incontinence. This includes detailed questions about the history and pattern of the problem: symptom pattern; type of leakage; stool consistency; cognition; and functional abilities. Additional questions assess related medical conditions and prior surgeries; medications (including herbal remedies); obstetric history; diet and fluid intake; and toilet access. Finally, it is necessary to rule out other signs or symptoms suggestive of bowel disease or colon cancer such as rectal bleeding, anaemia and unexplained weight loss.

Assessment of faecal incontinence should include an evaluation of the impact on the patient’s quality of life. This assessment should include patient-reported outcomes as clinicians tend to underestimate the impact of faecal incontinence on quality of life. The International Consultation on Incontinence Questionnaire – Bowel Symptoms (ICIQ-B) can be used to assess patterns of bowel activity and degree of defecatory control as well as the impact of faecal incontinence on the patient’s quality of life . Other commonly used questionnaires in research include the Faecal Incontinence Quality of life scale (FIQL) and the Faecal Incontinenece Severity Index (FISI) score.

Physical examination should include inspection of the skin; evaluation of faecal loading; presence of rectal prolapse or rectocele; presence of haemorrhoids; and pelvic floor muscle strength.

A bowel diary including food and fluid intake as well as the number, consistency and colour of bowel movements for a week is extremely helpful. This assists the healthcare professional in evaluating the severity of the faecal incontinence as well as dietary issues that may be affecting the bowel pattern.

Other investigations may be required to establish a diagnosis such as imaging of the anal sphincter muscles by ultrasound or MRI, inspection of the interior of the bowel (anoscopy/sigmoidoscppy/colonoscopy), or testing the nerve and muscle function of the lower bowel(anal manometry).

Treatment

Treatment will depend on the cause as well as whether the individual is an adult or a child. Education is the cornerstone of treatment for faecal incontinence. Patients require knowledge and understanding of anatomy, how to manage the condition and the causes of faecal incontinence. Caregivers, where appropriate, should be involved in this education.

Dietary modification is an important part of any treatment plan. Clients need coaching on soluble and insoluble fibre and monitoring, as response to fibre is different for every client. Clients should avoid foods that contribute to loose stool, such as lactose, sorbitol, fructose, caffeine and alcohol. Weight loss is thought to improve faecal incontinence but there is no research to support this. Expert opinion suggests that adequate fluid intake is important to prevent hard stool and constipation. Patients should track dietary intake using a bowel diary for a week. They can then determine patterns and triggers for incontinent episodes.

Bowel habit is important in preventing faecal incontinence. Patients should work to establish a regular, predictable pattern. For most, this involves having a bowel movement after breakfast to take advantage of the peristaltic contractions of the colon. Education should be provided on avoiding straining and sitting comfortably on the toilet with feet on the ground (or supported on a stool) and knees higher than the hips.

There is some evidence that pelvic floor muscle exercises are effective for patients who do not respond to other treatments. Bowel and anal sphincter retraining are commonly used. This training may involve the use of specialised equipment, termed “biofeedback”.

Anti-diarrhoea medication often helps those with incontinence of loose stool. Patients are instructed to titrate the dose upward as needed. Constipation may need to be treated with medications or enemas to relieve impaction.

Currently many minimally invasive therapeutic options are available . These include the use of injectibles (Solesta, Gatekeeper procedure) , radiofrequency stimulation (Secca Procedure) and sacral neuromodulation. Most recently, a less invasive form of neuromodulation, alteration of nerve function via electrical stimulation of the posterior tibial nerve of the ankle (PTNS or posterior /percutaneous tibial nerve stimulation), has been tried as a minimally invasive treatment for faecal incontinence.

Some causes of faecal incontinence may be surgically corrected. If the muscles have been damaged or severed, a sphincter repair may be indicated. More invasive options include the anal sphincter repair, graciloplasty and the artificial anal sphincters, all of which should be carried out in specialised centers. Rarely, diversion of the stool via colostomy is necessary to remedy the problem.

Newer options which are still under investigation include the posterior rectal sling (Topas) procedure. Future options could also include stem cell technology or creation of a neosphincter.

Conclusion

Faecal incontinence negatively affects quality of life. Sufferers describe spending considerable time and attention planning for accidents and the anxiety that these unpredictable episodes can generate. Additionally, many people with faecal incontinence make dramatic restrictions in their diet and report a lack of therapeutic guidance from health care professionals in this regard. Faecal incontinence has a negative impact on self-esteem and body image and creates feelings of shame and embarrassment. Faecal incontinence also affects patients’ sexuality as they worry about smells or accidents during intimacy.

More public awareness and professional interest are needed in the area of faecal incontinence as this common disorder can be managed or cured in most instances leading to a dramatic improvement in the patients’ quality of life.

References

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