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 time


• If 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.