Fecal incontinence

Fecal incontinence

ICD-10	R15
ICD-9	787.6

Fecal incontinence (or faecal incontinence, FI) is the loss of regular control of the bowels. Involuntary excretion and leaking are common occurrences for those affected. Subjects relating to defecation are often socially unacceptable, thus those affected may be beset by feelings of shame and humiliation. Some do not seek medical help and instead attempt to self-manage the problem. This can lead to social withdrawal and isolation, which can turn into cases of agoraphobia. Such effects may be reduced by undergoing prescribed treatment, taking prescribed medicine and making dietary changes.

Prevalence

Fecal incontinence affects people of all ages, but is more common in older adults than in younger adults. It is not, however, a normal part of aging.

Causes

Constipation

Constipation causes prolonged muscle stretching and leads to weakness of the intestinal muscles. After a certain point, the rectum will no longer close tightly enough to prevent stool loss, resulting in incontinence.^[1]

Muscle damage

Fecal incontinence can be caused by injury to one or both of the ring-like muscles at the end of the rectum called the internal and external anal sphincters. During normal function, these sphincters help retain stool. In women, damage can occur during childbirth. The risk of injury is greatest when the birth attendant uses forceps to help the delivery or does an episiotomy.^{[citation needed]} Hemorrhoid surgery can damage the sphincters as well.^{[citation needed]} A pelvic tumor that grows in or becomes attached to the rectum or anus also can cause muscle damage, as can surgery to remove the tumor.^{[citation needed]} Although anal sex resulting in repeated injury to the internal anal sphincter can lead to incontinence, the threat is relatively small.^[2] One study among 14 anoreceptive homosexual men and ten non-anoreceptive heterosexual men showed that anoreceptive homosexual men have decreased anal canal resting pressure relative to non-anoreceptive heterosexual men and no associated fecal incontinence.^[3] Another study among forty anoreceptive homosexual men and ten non-anoreceptive heterosexual men found a very significant increase in fecal incontinence (fourteen, or 35% amongst the anoreceptive men, and one, or 10% in the non-anoreceptive sample) amongst the anoreceptive sample.^[4]

Nerve damage

Fecal incontinence can also be caused by damage to the nerves that control the anal sphincters or to the nerves that detect stool in the rectum. Damage to the nerves controlling the sphincter muscles may render the muscles unable to work effectively. If the sensory nerves are damaged, detection of stool in the rectum is disabled, and one will not feel the need to defecate until too late. Nerve damage can be caused by childbirth, long-term constipation, stroke, and diseases that cause nerve degeneration, such as diabetes and multiple sclerosis.

Loss of storage capacity

Normally, the rectum stretches to hold stool until it is voluntarily released. But rectal surgery, radiation treatment, and inflammatory bowel disease can cause scarring, which may result in the walls of the rectum becoming stiff and less elastic. The rectum walls are unable to stretch as much and are unable to accommodate as much stool. Inflammatory bowel disease also can make rectal walls very irritated and thereby unable to contain stool.

Diarrhea

Main article: Diarrhea

Diarrhea, or loose stool, is more difficult to control than solid stool that is formed. Where diarrhea is caused by temporary problems such as mild infections or food reactions, incontinence tends to last for a period of days. Chronic conditions, such as irritable bowel syndrome, or Crohn's disease can cause severe diarrhea lasting for weeks or months until successful treatment can be found.

Pelvic floor dysfunction

Abnormalities of the pelvic floor can lead to fecal incontinence. Examples of some abnormalities are decreased perception of rectal sensation, decreased anal canal pressures, decreased squeeze pressure of the anal canal, impaired anal sensation, a dropping down of the rectum (rectal prolapse), protrusion of the rectum through the vagina (rectocele), and generalized weakness and sagging of the pelvic floor.

Other causes

Fecal incontinence can have other causes including one or a combination of the following:

• Excretory problems
• Fecal impaction
• Diseases, drugs, and indigestible dietary fats that interfere with the intestineal absorption. Respective examples include cystic fibrosis, orlistat, and olestra.
• Lateral internal sphincterotomy (Surgical procedure for helping Anal fissures heal)
• Seizure

Diagnosis

Severity scales

The Cleveland Clinic Incontinence Score is widely used because it is practical and easy to use and interpret. The score takes into account the frequency of incontinence and the use of pads and lifestyle alteration. A Fecal Incontinence Severity Index^[5] is based on a type-by-frequency matrix with four types of leakage (gas, mucus, liquid stool, solid stool) and five frequencies (one to three times per month, once per week, twice per week, once per day, twice or more per day).

Other tests include: AMS, Pescatori, Williams score, Kirwan, Miller score, Parks criteria, and the Vaizey scale.

Tests

Anorectal Manometry checks the tightness of the anal sphincter and its ability to respond to signals, as well as the sensitivity and function of the rectum. Endoanal ultrasound evaluates the structure of the anal sphincters. Proctography, also known as defecography, shows how much stool the rectum can hold, how well the rectum holds it, and how well the rectum can evacuate the stool. Proctosigmoidoscopy allows doctors to look inside the rectum for signs of disease or other problems that could cause fecal incontinence, such as inflammation, tumors, or scar tissue. Anal electromyography tests for nerve damage, which is often associated with obstetric injury.

Treatment

Treatment depends on the cause and severity of fecal incontinence; it may include dietary changes, medication, bowel training, or surgery. More than one treatment may be necessary because some forms of fecal incontinence can be rather complicated. Most physicians that specialize in gastroenterology, rehabilitative medicine, neurotrauma, and pediatric surgery have experience with bowel management programs. "Social continence" may be achievable for some people using a bowel management program that cleans out the colon daily. Cecostomy tube placement with antegrade enemas may benefit some patients.

Dietary changes

Food affects the consistency of stool and how quickly it passes through the digestive system. One way to help control fecal incontinence in some persons is to eat foods that add bulk to stool, decreasing the water content of the feces and making it firmer. Also, avoidance of foods and drinks such as those containing caffeine, which relax the internal anal sphincter muscle. Another approach is to eat foods low in fiber to decrease the work of the anal sphincters. Fruit can act as a natural laxative and should be eaten sparingly. Foods to be avoided also include those that typically cause diarrhea, such as cured or smoked meat; spicy foods; alcohol; dairy products; fatty and greasy foods; and artificial sweeteners.

Medication

Medication consists primarily of antipropulsive drugs.

Surgery

Surgical procedures used to treat otherwise intractable fecal incontinence include:

• Colostomy

• Cecostomy with antegrade enema program

• Stimulated graciloplasty creates a new anal sphincter, using gracilis muscle from the thigh and a temporary electric device to retrain the muscle for its new function.

• Artificial anal sphincter (also known as "artificial bowel sphincter" and "neosphincter").^[6] The usual surgical approach is through the perineum but because in many cases of fecal incontinence the perineum is damaged, for women an alternative approach is through the vagina.^[7]

• Temperature-controlled radiofrequency energy (SECCA)^[8]

• Antegrade continent enema stoma. This procedure is often necessary in addition to others when fecal incontinence is complicated by neuropathy and/or an incomplete internal anal sphincter.

• Sacral nerve stimulation, the newest of these surgical procedures, involves implanting an electric device that may enable control of the anal sphincter and restore a patient's continence. [1]

Graciloplasty and artificial anal sphincter both significantly improve continence, with artificial anal sphincter being superior,^[9] however both methods have high rates of complications.^[9][10]

Kegel exercises

Appropriate exercise of the sphincter muscles (Kegel exercise) can help restore muscle tone, and reduce or even eliminate anal incontinence.^[11]

See also

• Encopresis
• Steatorrhea
• National Public Toilet Map

References

1. ^ "NIH MedlinePlus - Bowel Incontinence". http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/003135.htm. Retrieved 2008-08-08. 
2. ^ "Duke Student Health Center - Anal Stimulation and Intercourse". Archived from the original on 2008-04-18. http://web.archive.org/web/20080418103010/http://healthydevil.studentaffairs.duke.edu/health_info/Anal+Stimulation+and+Intercourse.html. Retrieved 2008-08-08. 
3. ^ Chun AB, Rose S, Mitrani C, Silvestre AJ, Wald A. (Mar 1997). "Anal sphincter structure and function in homosexual males engaging in anoreceptive intercourse". Am J Gastroenterol 92 (3): 465–468. PMID 9068471. 
4. ^ Miles AJ, Allen-Mersh TG, Wastell C. (Mar 1993). "Effect of anoreceptive intercourse on anorectal function". J R Soc Med 86 (3): 144–147. PMC 1293903. PMID 8459377. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1293903. 
5. ^ Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC (1999). "Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index". Dis. Colon Rectum 42 (12): 1525–32. doi:10.1007/BF02236199. PMID 10613469. 
6. ^ Schrag HJ, Ruthmann O, Doll A, Goldschmidtböing F, Woias P, Hopt UT (2006). "Development of a novel, remote-controlled artificial bowel sphincter through microsystems technology". Artif Organs 30 (11): 855–62. doi:10.1111/j.1525-1594.2006.00312.x. PMID 17062108. http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0160-564X&date=2006&volume=30&issue=11&spage=855. 
7. ^ Michot F, Tuech JJ, Lefebure B, Bridoux V, Denis P (2007). "A new implantation procedure of artificial sphincter for anal incontinence: the transvaginal approach". Dis. Colon Rectum 50 (9): 1401–4. doi:10.1007/s10350-007-0314-6. PMID 17665251. 
8. ^ Felt-Bersma RJ, Szojda MM, Mulder CJ (2007). "Temperature-controlled radiofrequency energy (SECCA) to the anal canal for the treatment of faecal incontinence offers moderate improvement". Eur J Gastroenterol Hepatol 19 (7): 575–80. doi:10.1097/MEG.0b013e32811ec010. PMID 17556904. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?an=00042737-200707000-00010. 
9. ^ ^{a b} Ruthmann O, Fischer A, Hopt UT, Schrag HJ (2006). "[Dynamic graciloplasty vs artificial bowel sphincter in the management of severe fecal incontinence]" (in German). Chirurg 77 (10): 926–38. doi:10.1007/s00104-006-1217-0. PMID 16896900. 
10. ^ Belyaev O, Müller C, Uhl W (2006). "Neosphincter surgery for fecal incontinence: a critical and unbiased review of the relevant literature". Surg. Today 36 (4): 295–303. doi:10.1007/s00595-005-3159-4. PMID 16554983. 
11. ^ "The Continence Foundation - Sphincter Exercises to Aid Bowel Control". Archived from the original on 2008-06-26. http://web.archive.org/web/20080626223203/http://www.continence-foundation.org.uk/publications/pdfs/Sphincter+Exercises+9.PDF. Retrieved 2008-05-14. 

External links

• The National Association For Continence (NAFC)
• Consensus Conference: Treatment Options for Fecal Incontinence. Saint Vincent Oct 2002
• The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
• Arkansas Spinal Cord Commission (ASCC)
• NICE guidance IPG159: Stimulated graciloplasty for faecal incontinence
• NICE guidance IPG099: Sacral nerve stimulation for faecal incontinence