Faecal incontinence is being unable to control solid or liquid stool, so that stool passes from the back passage involuntarily. In some patients it appears only as leakage of mucus or stool and staining of the underwear.

Faecal incontinence can affect a person’s daily life, their social relationships and their quality of life considerably. But the underlying cause can usually be investigated, and the complaints can be reduced with appropriate treatment.

Faecal incontinence is not an inevitable or normal consequence of getting older.

How is bowel control maintained?

Normal bowel control does not depend on a single muscle. Several structures have to work together:

The rectum: stores the stool temporarily.
The internal anal sphincter: helps keep the anus closed at rest.
The external anal sphincter: contracts voluntarily when needed and holds the stool in.
The pelvic floor muscles: support bowel control.
Sensation and the nervous system: detect that stool has arrived in the rectum and signal it to the brain.
The consistency of the stool: very liquid stool is harder to hold than stool of a normal consistency.

A disturbance in one or more of these mechanisms can lead to loss of bowel control.

What causes faecal incontinence?

Faecal incontinence has many different causes, and sometimes more than one is present in the same patient.

Diarrhoea

Watery stool is harder to hold than solid stool. Chronic or recurrent diarrhoea is one of the important causes of faecal incontinence.

Irritable bowel syndrome (IBS), inflammatory bowel disease, infections and other causes of diarrhoea can all make bowel control more difficult.

Constipation and stool impaction

Hard stool can build up in the rectum in long-standing constipation. Liquid stool can then leak out around the impacted hard stool. This is seen particularly at older ages.

Damage to the anal sphincter muscles

Damage to the muscles that close the anal canal can impair bowel control.

Sphincter damage can develop after:

Difficult or traumatic vaginal delivery
Tears occurring during childbirth
Certain anorectal operations
Trauma to the anal region

Some sphincter injuries occurring during childbirth can remain silent for years, with the complaints appearing at an older age.

Nerve damage

Damage to the nerves that control the anal sphincters and the pelvic floor can impair bowel control.

Diabetes, diseases or injuries of the spinal cord, certain neurological diseases and long-standing straining can all affect nerve function.

Impaired sensation or capacity of the rectum

The rectum should normally be able to store stool for a while. Inflammation of the rectum, and changes occurring after surgery or radiotherapy, can reduce that capacity.

Pelvic floor disorders

Weakening of the pelvic floor muscles, and conditions such as rectal prolapse or rectocele, can also impair bowel control.

What are the types of faecal incontinence?

Urge incontinence

The patient feels the need to open their bowels but cannot hold the stool long enough, and loses it before reaching the toilet.

Passive incontinence

The patient may lose stool or mucus without feeling the need to open their bowels. It is seen particularly where anal sphincter function or rectal sensation is impaired.

Post-defaecation leakage

Leakage of stool or mucus can occur for a period after the bowels have been opened.

What are the symptoms?

In faecal incontinence there may be:

Involuntary loss of wind
Loss of liquid or solid stool
Staining of the underwear with stool or mucus
A sudden need to open the bowels
Not reaching the toilet in time
Leakage after opening the bowels
Irritation, burning or itching around the anus
Anxiety about odour

In some people the problem arises only during diarrhoea; in more advanced cases, difficulty can develop in controlling stool of a normal consistency as well.

How is the diagnosis made?

The first and most important stage of the diagnosis is a detailed history and physical examination.

The doctor will ask:

How long the incontinence has been present
How often it occurs
Whether it is liquid or solid stool that is lost
Whether there is a sense of urgency beforehand
Whether there is diarrhoea or constipation
About previous deliveries
About operations
About the medicines being taken
About any accompanying bowel disease

The patient keeping a bowel diary for a few weeks can be useful in reaching the diagnosis.

The anal region is assessed on physical examination, and a rectal examination may be performed.

Which tests might be needed?

Not every patient needs all the tests. The investigations are chosen according to the patient’s complaints and the examination findings.

Colonoscopy

This is not a test that measures faecal incontinence directly.

But it may be needed to assess the colon, particularly in people with diarrhoea, bleeding from the back passage, anaemia, a new change in bowel habit, or a suspicion of some other bowel disease.

Anorectal manometry

This helps to assess the pressure of the anal sphincters, the sensation of the rectum and anorectal function.

Endoanal ultrasound

This can be useful particularly in patients in whom structural damage or a tear in the anal sphincter muscles is suspected. It can be used to demonstrate sphincter damage related to childbirth or previous operations.

Defaecography or pelvic MRI

These can be used in selected patients to assess bowel-emptying function and the structures of the pelvic floor.

How is faecal incontinence treated?

Treatment is planned individually according to the underlying cause.

The aim is not merely to reduce the number of accidents, but to improve the patient’s bowel control and quality of life as far as possible.

Correcting diarrhoea or constipation

If there is diarrhoea, its cause is investigated and treated appropriately.

If there is constipation and stool build-up in the rectum, this has to be corrected first.

The aim is for the stool to be neither too liquid nor too hard.

Adjusting the diet

It can be useful for the patient to identify which foods make their complaints worse.

A food and bowel diary can be kept.

Fibre intake can help to regulate stool consistency in some patients. But the amount and type of fibre has to be individualised according to whether the patient has diarrhoea or constipation.

Medical treatment

In suitable patients where diarrhoea predominates, medicines can be used to reduce the frequency of bowel movements and the sense of urgency.

Where there is overflow incontinence due to constipation, the treatment is entirely different.

It is therefore not appropriate for someone with faecal incontinence to take antidiarrhoeals or laxatives continuously on their own initiative.

Pelvic floor exercises

Exercises to strengthen the pelvic floor and anal sphincter muscles can improve bowel control in some patients.

Learning the exercises correctly matters, and support can be obtained from physiotherapists trained in this area where needed.

Biofeedback

Biofeedback is a treatment intended to teach the patient to use the anal and pelvic floor muscles more effectively.

It can also help to develop a better awareness of stool arriving in the rectum and the ability to control the sudden urge to open the bowels.

Sacral neuromodulation

Sacral neuromodulation can be considered in selected patients whose faecal incontinence remains marked despite conservative treatment.

In this method, a low level of electrical stimulation is applied to the sacral nerves related to bowel and anal sphincter function.

Surgery

Surgical treatment can come into consideration in selected patients with marked anatomical damage to the anal sphincter, or whose serious complaints persist despite other treatments.

The method used is decided according to the structure of the patient’s sphincter, the cause of the incontinence, their age and any other accompanying pelvic floor problems.

Why does skin care matter?

Repeated contact with stool can cause redness, burning and irritation of the skin around the anus.

Cleaning the area gently and keeping it dry matters. Appropriate barrier creams and protective products can be used where needed.

What can be done in daily life?

Until the treatment takes effect, the following can help to make daily life easier:

Not putting off going to the toilet
Developing a regular toilet habit, particularly after meals
Knowing where the toilets are before going out
Using a protective pad where needed
Carrying a spare change of underwear
Paying attention to skin care

When should a doctor be seen?

Medical assessment matters particularly in the following situations:

The incontinence has only recently begun
The complaints are steadily increasing
It is affecting daily or social life
There is bleeding from the back passage or blood in the stool
There is unexplained weight loss or anaemia
There is long-standing diarrhoea or marked constipation alongside it
There is severe abdominal pain or fever
The complaints persist despite treatment

Remember

Faecal incontinence is not something to be ashamed of or to hide. It is a medical problem to be investigated and treated.

The cause is not the same in every patient. The options range from relatively simple measures such as correcting diarrhoea or constipation, through pelvic floor treatment, biofeedback and sacral neuromodulation, to surgery in selected patients.

Faecal Incontinence (Loss of Bowel Control)