Incontinence IncontinenceTreatment Loss of control - faecal incontinence Maintaining bowel control. Accidents or being caught short are fortunately a rare event for most of us - perhaps occurring at the time of a diarrhoeal illness. However more frequent loss of control is another issue. Control is maintained by two sphincters - muscular rings at the anus. The internal sphincter is not under voluntary control. It remains closed without our conscious effort. The outer ring or external sphincter can be closed voluntarily.We use this to provide extra protection in extreme urgency or to maintain control with coughing , sneezing etc. Damage to these sphincters or damage to the nerves that supply the sphincters can cause problems with continence. There are three types of incontinence. Involuntary discharge of stool or gas without awareness. Urge incontinence. This is discharge in spite of attempts to retain bowel contents. i.e unable to hold on! Seepage or leakage of small amounts - staining of underclothes. What causes loss of control? The most common problems are: Birth defects - born with abnormal sphincters. Following childbirth. This is more likely to have sphincter damage after prolonged labour, difficult forceps, breech delivery and may be associated with deep vaginal tear but not always.The problems may not be apparent at the time but becomes an issue in later life.This may be because of some gradual loss of tissue "tone" or if a new bowel problem develops than "overwhelms" a weak sphincter. Diarrhoeal diseases leading to urgency and losseness that overwhelms the defences. Obviously the more liquid the worse the problem.Some colonic "irritants" bile salts / excess laxative use - may cause a similar problem. Elderly – gradual loss of tissue strength over time. Impaction with leakage around a full rectum. This mostly occurs in the elderly who may not be aware of developing severe constipation. Then present with leakage / incontinence. Often the diagnosis is delayed. Neurological problems such as multiple sclerosis, stroke, spinal cord injury, diabetes (may lead to nerve damage). Intact sensation is essential to be aware of imminent need to pass a bowel motion and todistinguish between formed stool, liquid and gas.i.e knowing when it is safe pass gas! Small rectum / decreased rectal compliance or accommodation. Less ability to store faeces until "ready" to pass a bowel motion.This may be caused by chronic inflammation - diseases such as colitis / Crohn's disease,post radiotherapy, post-surgical changes. Pelvic floor problems.Nerve damage as the result of long-term straining or from rectal prolapse. Investigation Examination by a specialist can provide a lot of information. Anorectal ultrasound (looking for evidence of an anal sphincter tear may be required).MRI is another way of looking at the integrity of the anal sphincters and pelvic floor. A special X-ray looking for any disorder of defaecation may help. This is called a defaecating proctogram. Specialized testing of the anal sphincters and the pressures in the rectum may be required. This is manometry or pressure studies usually combined with nerve testing - especially the pudendal nerve. Some foods may be aggravating the problem. Coffee creates urgency - should be stopped completely.Spicy foods, alcohol, fruit juices (see diet and irritable bowel).Too much wind can aggravate the problem. Reduce high fibre bread and wind-forming vegetables.Slowing down the bowel habit can provide continence even if the sphincters are weak. Regular loperamide – may be 1-3 capsules per day.Whatever dose is required to get firmer motions without urgency and without causing constipation.Episodes of urgency and incontinence associated with IBS can often be managed with small but regular doses of loperamide - in this situation I start at 1/2 tablet daily. loperamide is available as capsule or tablet on prescription - obviously the tablet will be necessary if only 1/2 tablet is required This is often very helpful and can transform the lives of some people.There is no problem with regular loperamide taken over a long period of timeIf the problem is impaction of faeces in the rectum then this needs to be cleared. This often involves treatment from both ends!!The best treatment is the use of PEG solution (Klean Prep, Glycoprep) as used for preparation for colonoscopy.Phosphate enemas (Fleet enemas) can be given from below.Sometimes surgery to repair a sphincter tear can help. 80% have some benefit.Less effect with time - perhaps only 1/2 have good effect at 5 years.Sometimes biofeedback can improve sphincter tone. The aim is to improve strength of the anal sphincters.To improve co-ordination and enhance sensation in the rectum.Most effective with "urge incontinence".Sometimes the problem relates to ineffective defaecation leaving some faeces close to the anal canal. This problem is often aggravating by bowel slowing medication.Sometimes this is better with fibre supplements (e.g Normacol).Treatment of constipation with lactulose often leads to seepage of liquid faeces.This can be improved with biofeedback or sometimes operations to treatment rectal prolapse (requires specialist assessment).Other types of surgery to repair or replace the sphincters are possible. Sacral nerve stimulation is available in main centres for a limited number of patients that fail more simple approaches If all else fails a colostomy is a good solution.The important thing is not be embarrassed and to start the process of assessment – there are good success rates with treatment.