Asked by Josephine , Sydney, Australia
I am having trouble with losing control of my bowels while away from home. My husband and I want to travel, but I am scared stiff of doing that with this problem. Is there surgery that can be done? Would exercises work?
Dr. Otis Brawley
Chief Medical Officer,
American Cancer Society
Thank you for your question. This is an extremely important issue. Fecal incontinence is very common. It is categorized as minor when there is inadvertent escape of flatus and slight soiling of undergarments or as major when there is the involuntary excretion of feces and significant soiling. Incontinence affects perhaps as many as 3 percent of people in their 20s and 20 percent of people in their 70s. It can be emotionally devastating. Studies suggest that as many as two-thirds of patients with this problem will not discuss it with their doctors.
There are a number of considerations in evaluating fecal incontinence. They include: stool volume and consistency, and stool transit time through the colon. Anatomic factors are also considered such as lack of flexibility of the rectum, the function of the muscles of the anal sphincters -- muscles that contract around the opening -- and sensation and nerve reflexes in the anus and rectum. Incontinence commonly results from a problem with more than one of the above.
Inflammation of the rectum due to ulcerative proctitis, a disease called amyloidosis, or radiation proctitis can lead to rectal distensibility problems, meaning the rectum cannot expand and hold stool. Dysfunction of the anal sphincters and impaired rectal sensation can occur because of trauma from childbirth, which can stretch and damage muscles and nerves or it can be due to anal surgery for diseases like hemorrhoids. Some neurologic disorders caused by diabetes, multiple sclerosis or spinal cord injury can also cause dysfunction of the sphincters.
Interestingly some patients with frequent constipation will have incontinence because of a partial blocking of the bowel with hard stool. This is called impaction and can lead to liquid stool leaking around the blockage and incontinence.
Evaluation of incontinence is usually best done by a gastroenterologist or a colorectal surgeon. It begins with a good medical history and physical examination. Flexible sigmoidoscopy or colonoscopy is done to exclude bowel inflammation, masses, or other pathology. For those with diarrhea, appropriate testing may include culture for common bacterial pathogens and even some parasites. Clostridium difficile, a bacterial overgrowth due to antibiotic therapy, is a common finding. A variety of other tests may be used to measure specific anatomic components of anorectal function. Attention should also be given to medications taken. For example, metformin, commonly used to treat diabetes, is a common cause of diarrhea and incontinence.
For many, the cause of incontinence cannot be found even after full evaluation. When the treatment cannot focus on the known cause, it should focus on dominant symptoms. Useful medical therapies include anti-diarrheal drugs to cause a mild constipation. A physician might recommend a trial of:
• The bulking agent methylcellulose, which can be especially useful for those with diarrhea-related incontinence.
• Loperamide, which can reduce urgency and as a side effect increases internal anal sphincter tone.
• Anticholinergic agents (such as hyoscyamine) taken before meals can be especially good for those with post-meal incontinence. These drugs slow the passage of stool through the bowel and decrease the amount of water in the stool.
• The tricyclic antidepressant amitriptyline has some success in nondepressed patients with fecal incontinence of unknown cause. It appears to strengthen the muscles of the anal sphincter and may also decrease the liquid content of stool.
Surgical approaches to fecal incontinence are appropriate in some patients with a sphincter tear from obstetrical trauma, or some other discrete anal or rectal damage from other types of injury.
Biofeedback therapy is controversial but advocated by some. It is an attempt to retrain and strengthen the pelvic floor muscles and the abdominal wall musculature. The patient regularly inserts an anal plug with electromyographic electrodes, applies electrodes to the abdominal wall and does exercises. In one randomized study, 54 percent of people seemed to benefit from biofeedback therapy, but 53 percent of those randomized to counseling only also benefited.
Supportive measures include avoiding foods associated with symptoms such as those containing caffeine or stopping activities such as exercise after eating that worsen symptoms. Trying to ritualize bowel habits to specific times of the day can also be helpful. Patients with incontinence must pay special attention to skin hygiene around the anus. Measures that can help include use of moist tissues such as baby wipes, and use of barrier zinc oxide commonly marketed as a diaper cream.
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