Fecal incontinence is the inability to control the passage of bowel movements, causing stool and gas to be unexpectedly released from the rectum. It is a symptom of an underlying medical condition, not a disease in itself.

More than 5.5 million Americans experience fecal incontinence, according to the National Institutes of Health (NIH). It is more common in women and older adults, but is not considered a normal part of the aging process. Health conditions that may cause fecal incontinence include constipation, diarrhea, muscle damage, nerve damage and pelvic floor dysfunction (difficult or painful bowel movements).

To determine the cause of fecal incontinence, a physician will perform a physical examination including a digital rectal exam (DRE) and other diagnostic tests, such as an anal manometry (evaluates anal sensation, pressure and elasticity), anorectal ultrasonography (evaluates the structure of the anal sphincter) and defecography (determines how much stool the rectum can hold).

Treatment varies according to the cause and severity of the fecal incontinence. It may consist of making dietary modifications or performing special exercises to strengthen the rectum. In some cases, medication or surgery may be needed.

Fecal incontinence may sometimes be prevented when its cause (e.g., constipation, diarrhea) can be prevented. Although many people who experience fecal incontinence may be embarrassed to seek help, treatment often provides some relief from symptoms. In cases where the incontinence is not completely relieved through treatment, various actions can be taken to improve the quality of life for patients with fecal incontinence.

Fecal incontinence, also called bowel incontinence, is the continuous or recurrent loss of fecal material in individuals older than age 4. It results in the involuntary release of stool (feces) and gas from the rectum. Fecal incontinence can range from the occasional leakage of stool while passing gas to a complete loss of bowel control. It may involve stool that is solid, liquid or a simultaneous combination of both.

Food enters the digestive tract (passage through which food moves for digestion) at the mouth and exits at the anus. Most nutrients are absorbed from food as it travels through the small intestine (where most digestion occurs). Most water and salt are absorbed by the body during transport through the large intestine (lower portion of the digestive tract consisting of the colon and rectum). What remains is waste material (stool) consisting of undigested food, unabsorbed water, bacteria, mucus and dead cells.

In normal digestion, stool enters the rectum where it is stored. As the rectum fills with stool, it triggers the surrounding muscles to tighten the anal sphincters (the ring of muscles at the end of the rectum that holds in stool). Stool should remain in the rectum until a bowel movement is voluntarily initiated.

Normal functioning of the rectum and anus are necessary to hold stool in the rectum until ready for a bowel movement. Fecal incontinence may occur when:

• Anal sphincter is too weak to hold stool in the rectum
• Sensation of the rectum being full is lessened
• Rectum loses its ability to store stool

Fecal incontinence often involves messy contact between liquid or watery stool and the sensitive skin around the anus. This can cause pain and itching, which may be further aggravated by constant wiping of the area or use of substances that can irritate the skin.

In addition, patients with fecal incontinence due to pelvic floor dysfunction may also experience urinary incontinence (inability to control the bladder).

Estimating the number of people that experience fecal incontinence can be difficult because many people do not seek treatment out of embarrassment. According to the National Institutes of Health (NIH), more than 5.5 million Americans experience fecal incontinence. People of all ages are affected by the condition, although it is more common in women and older adults. Fecal incontinence is not considered a normal part of the aging process.

Most people who seek treatment for fecal incontinence experience some relief of symptoms. For some individuals, treatment resolves the problem completely.

Problems with the normal functioning of the rectum, anus or central nervous system (CNS) can lead to fecal incontinence. Such difficulties may include:

• Constipation. Difficulty passing hard, dry stool (feces) or the inability to pass stool. This is one of the most common causes of fecal incontinence. Constipation causes large, hard stools to become lodged in the rectum. Watery stool can then leak out around the hardened stool. Constipation also causes the rectal muscles to stretch, which weakens them so they cannot hold stool long enough for a person to reach the toilet.
• Diarrhea. Loose or watery stool. It is more difficult to control loose stool than solid stool, which can result in fecal incontinence. Diarrhea can cause an accident even in people who do not have incontinence.
• Muscle damage. Damage to the anal sphincter muscles can prevent them from tightening enough to keep stool inside the rectum. Muscle damage may be caused by experiences such as vaginal childbirth (especially multiple births) or anal surgery (e.g., hemorrhoid surgery). An episiotomy (incision made to enlarge the vaginal opening) during childbirth may increase the likelihood of sphincter muscle damage that can lead to fecal incontinence. Hysterectomy (surgical removal of the uterus) may also increase the risk of fecal incontinence.
  
  In addition, fecal incontinence is more common among older adults than younger age groups, partially because the elderly experience a general muscle weakening that occurs with age.
• Nerve damage. Problems with nerves that control rectal and anal sphincter activity can result in the inability to sense fullness of the bowel. This may lead to the unexpected release of stool because the sensation that usually precedes and indicates readiness for a bowel movement does not occur. Nerve problems may also prevent sphincter muscles from properly tightening, allowing stool to spill from the rectum.
  
  Nerve damage may be due to a number of conditions or events, which can range from childbirth to stroke. For instance, the use of forceps during delivery may increase the risk of nerve damage that can lead to fecal incontinence. Nerve damage may develop over time due to injury or disease, such as diabetes (the body’s inability to break down blood sugar), multiple sclerosis (an autoimmune disease affecting the central nervous system), and dementia (impairment of brain functioning). Nerves can also become damaged in people with a long-term habit of straining to pass stool.
  
  
• Loss of storage capacity. Normally, the rectum stretches to hold stool. However, scarring of rectal tissue can make the walls of the rectum stiff and less elastic. When the rectum cannot stretch as much, it cannot hold as much stool, causing fecal incontinence. Rectal surgery, radiation treatment and inflammatory bowel disease (IBS) can all cause rectal scarring. IBS also can make rectal walls irritated and unable to contain stool.
• Hemorrhoids. May prevent the anal sphincters from closing and cause fecal incontinence.
• Pelvic floor dysfunction. Problems with the layers of muscles and connective tissue that form the floor of the pelvis and help to maintain continence (the ability to control the timing of a bowel movement or urination). Childbirth is the most common cause of pelvic floor dysfunction in women. Other causes of pelvic floor dysfunction include:
  
  
  • Decreased perception of rectal sensation
    
  • Decreased anal canal pressure
  • Impaired anal sensation
  • Rectal prolapse (a dropping down of the rectum)
  • Rectocele (protrusion of the rectum through the vagina)
  • Generalized weakness and sagging of the pelvic floor

Sometimes the cause of fecal incontinence cannot be determined (idiopathic). This occurs most commonly in middle-aged or older women.

The first step in diagnosing fecal incontinence is a physical examination including medical history that includes a description of symptoms and list of current medications. A physician will visually inspect the anus and perineum (area lying between the anus and genitals) for conditions that may cause fecal incontinence.

A physician may also use a gentle prodding device or probe to examine the area. This includes touching the external anal sphincter (ring-like muscles at the end of the rectum), which normally causes the sphincter muscles to contract and the anus to pucker. This is called an anocutaneous reflex or anal wink test. Failure of the anus to respond to touch may indicate nerve damage. A physician may also perform a digital rectal exam (DRE), which involves inserting a gloved and lubricated finger into the rectum to evaluate the strength of the sphincter muscles and check for abnormalities.

Other tests that may be performed depending on the suspected cause of the incontinence include:

• Fecal tests. Laboratory examination of a sample of stool (feces). Fecal tests may be used by physicians to identify the cause of fecal incontinence in patients with diarrhea.
• Anal manometry. A common test of anal pressure, rectal elasticity and sensation. A narrow, flexible tube is inserted into the anus and rectum. A small balloon at the end of the tube may be expanded to measure the tightness, sensitivity and function of the anal sphincters. This test may reveal problems with muscle tone or impairment of rectal reflexes or sensation.
• Anorectal ultrasonography. Uses sound waves to produce images of the anal sphincter structure. The physician inserts a narrow, wand-like instrument into the anus and rectum that emits sound waves. Images are produced on an attached computer screen. This test can reveal structural abnormalities of the anal sphincters, rectal wall and the pelvic muscles that help maintain continence.
• Proctography. Also known as defecography, it determines the ability of the rectum to hold and release stool. In this test, a thick barium paste is inserted through the anus, coating the walls of the rectum. X-rays are taken during rest, straining and release of the paste from the bowels. This test may also reveal structural abnormalities in the rectal and anal areas.
• Proctosigmoidoscopy. This test allows physicians to look inside the rectum for signs of disease and other problems that can cause fecal incontinence. The physician uses a long, slender tube with a tiny video camera attached to examine the rectum and sigmoid (the last two feet of the colon). The test detects signs of inflammation, tumors or scar tissue that may cause fecal incontinence. Tissue samples may be removed for analysis under a microscope.
• Colonoscopy. Similar to a proctosigmoidoscopy, except that the tube is inserted farther up the digestive tract, allowing examination of the entire large intestine.
• Anal electromyography. Detects nerve damage or muscular causes for poor anal sphincter function by inserting tiny needle electrodes into muscles around the anus.
• Nerve conduction tests. Electrical impulses are delivered into the rectum to trigger muscle contraction. Physicians may use a glove containing a stimulating electrode in the finger, which is then inserted into the anus. These tests measure the speed between the stimulating impulse and the muscle contraction. Delay may indicate damage to the pudendal nerve that controls anal sphincter muscles, causing fecal incontinence.

Some gynecologists have undergone advanced pelvic surgery training and have the necessary skills and experience to diagnose and treat fecal incontinence. However, it is more likely that the gynecologist will refer the patient to other specialists. These may include:

• Gastroenterologists. Physicians specializing in the diagnosis and treatment of diseases of the digestive system.
• Proctologists. Physicians specializing in diseases of the colon, rectum and anus.
• Colorectal surgeons. Physicians specializing in the diagnosis and surgical treatment of benign and malignant (cancerous) diseases of the colon, rectum and anus.

The type of treatment a patient receives depends upon the cause and severity of the fecal incontinence. Treatment may consist of dietary changes, medication, bowel training (behavioral programs to establish or re-establish regular bowel control) or surgery.

Certain foods and eating behaviors can affect the consistency of stool, which may cause diarrhea or constipation and lead to fecal incontinence. Making simple dietary changes can help patients manage fecal incontinence. Recommended diet modification techniques include:

• Keeping a food diary. Make a list of foods eaten, time of consumption and incidences of fecal incontinence. Patterns between foods consumed and incontinence may emerge.
• Eating smaller meals more frequently during the day. Eating six small meals a day instead of three large ones may reduce fecal incontinence. Large meals cause bowel contractions in some people.
• Eating and drinking at separate times. Liquid helps move food through the digestive system, which may contribute to diarrhea in some people. To slow the process, drink fluids a half hour before meals and avoid fluid consumption while eating.
• Consuming adequate amounts of fiber. Soluble fiber (e.g., oatmeal, rye, navy beans) is digestible and makes stool soft, formed and easier to control. However, eating too much insoluble fiber (e.g., whole grain breads and cereals), which is indigestible, can contribute to diarrhea. It is important to note that most fiber-rich foods contain both soluble and insoluble fiber. Patients making dietary changes should learn which foods are most likely to benefit them.
  
• Drinking plenty of fluids. Drinking eight 8-ounce glasses of water a day prevents dehydration and keeps stool soft and formed. However, drinks with alcohol, milk or carbonation (e.g., sodas) should be avoided because they can trigger diarrhea and fecal incontinence.
  
  
• Avoiding caffeine. Drinks and food containing caffeine (e.g., coffee, tea, soda and chocolate) may worsen fecal incontinence because caffeine acts as a laxative and relaxes internal and external anal sphincter muscles.

If dietary changes alone are not effective, medications may be used to treat fecal incontinence. These may include:

• Bulk laxatives. Products that increase fecal volume to stimulate bowel movement. They help regulate bowel movements, alleviating diarrhea or constipation associated with fecal incontinence. Patients should consult with their physicians before using any type of laxative, since chronic use of some laxatives can actually cause constipation and may lead to fecal incontinence.
• Anticholinergics. Medicines that reduce spontaneous motions of the bowels (bowel motility).
• Antidiarrheals. Medicines slow down the bowels and prevent diarrhea.

Bowel training can help some people control their bowels. In some cases, it involves strengthening the muscles. In others, it involves training the bowels to empty at a specific time during the day. There are two techniques:

• Develop a regular pattern of bowel movements. Establishing a pattern of defecation during specific times of the day (e.g., upon awakening, after meals) can help regulate bowel functioning and may be beneficial for patients with fecal incontinence caused by constipation.
• Biofeedback. A treatment technique in which people are trained to improve their health by using signals from their own bodies. Special computer equipment measures muscle contractions while exercises are performed to strengthen the rectum. Computer feedback demonstrates whether the exercises are effective. 

In some cases of fecal incontinence, surgery is necessary to treat the underlying problem. Some common surgical options include:

• Sphincteroplasty. Surgery to repair a damaged or weakened anal sphincter. During this procedure, an injured area of muscle is identified and its edges are freed from the surrounding tissue. The muscle edges are then brought back and sewn together in an overlapping fashion. This strengthens the muscles, tightening the sphincter. This is most effective for people with a single site anal sphincter injury.
• Repair of rectal prolapse (which weakens the anal sphincter). In certain circumstances, such as chronic constipation and straining, the rectum ligaments can become stretched and lose their ability to hold the rectum in place. Surgical correction of rectal prolapse may be needed along with sphincter muscle repair.
• Repair of a rectocele (protrusion of the rectum through the vagina). This may need to be treated surgically to correct fecal incontinence.
• Hemorrhoidectomy. Surgery to remove hemorrhoidal tissue. Hemorrhoids may be internal (near the beginning of the anal canal) or external (at the lower portion of the anal opening). Prolapsed internal hemorrhoids may prevent complete closure of the anal sphincter, leading to fecal incontinence.
• Sphincter replacement. An artificial anal sphincter is used to replace a damaged one. The device is an inflatable cuff implanted around the anal canal. When inflated, it keeps the anal sphincter closed. To release stool, a small external pump is used to deflate the device, which reinflates on its own 10 minutes later.
• Gracilis muscle transplant. Surgical repair of the anal sphincter in which a muscle is taken from the inner thigh and wrapped around the sphincter. This restores muscle tone to the sphincter.
• Sacral nerve stimulation. A small device called a sacral nerve stimulator is implanted under the skin in the abdomen. A wire from the device is connected to a sacral nerve, a nerve involved in bowel and anal sphincter control. Through the wire, the device emits electrical pulses that control bowel and anal sphincter function. Recent research shows sacral nerve stimulation to be very effective in relieving fecal incontinence.
• Colostomy. Surgery performed to divert stool through an opening in the abdomen instead of through the rectum. A special bag (colostomy bag) is attached to the opening to collect the stool. Performed as a last resort, this may be the only definitive way to correct fecal incontinence, particularly in older adults.

Treating anal discomfort (e.g., pain, itchiness) that can accompany fecal incontinence involves keeping the anal area clean and dry. Some tips include:

• Wash area with water, but no soap. Soap can dry out the sensitive skin around the anus, worsening any discomfort in the area. The anal area should be washed with water after each bowel movement. This can be done in the shower or via a sitz bath. Let the anal area air-dry after washing.
• Use premoistened, alcohol-free towelettes instead of toilet paper. Wiping the anal area with these towelettes keep the area clean without the irritation of dry toilet paper against the skin.
• Protect area with special creams and powders. Moisture barrier creams protect skin from contact with stool. Non-medicated talcum powder or cornstarch may relieve anal discomfort. The anal area should be cleaned prior to application to prevent trapping bacteria in the area. Patients should consult their physician before using anal ointments because some may irritate the skin.
• Wear cotton underwear. Cotton absorbs moisture, letting the skin breathe and preventing the area from staying wet and worsening irritation of the area.
• Buy disposable products with a protective top layer. Protective pads or disposable underwear should have an absorbent wicking layer on top that pulls moisture away from your skin.
• Change soiled garments immediately. Removing soiled garments as soon as possible after an incident of fecal incontinence limits the amount of contact between stool and skin.

Depending on the cause, some types of fecal incontinence may be prevented. Some prevention techniques include:

• Reducing constipation. Fecal incontinence due to chronic constipation can be improved or eliminated by treating the constipation. Tips include getting more exercise, eating high-fiber foods and drinking plenty of fluids. Taking fiber supplements can also reduce constipation.
  
  
• Controlling or preventing diarrhea. Treating the cause of diarrhea, such as an intestinal infection, may prevent fecal incontinence. Some people can prevent diarrhea by avoiding foods that contain sugars such as lactose (from milk), fructose (from fruit) and sorbitol (from berries and other fruits).
  
  
• Avoiding straining. Straining during bowel movements may weaken anal sphincter muscles which can lead to fecal incontinence.

People prone to diarrhea or constipation should see a physician to determine if an underlying disorder is causing these symptoms. Early detection and treatment of any such problems can prevent constipation or diarrhea that may lead to fecal incontinence.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about fecal incontinence:

1. What is causing my fecal incontinence?
   
   
2. If I’m experiencing fecal incontinence, will I also experience urinary incontinence?
   
   
3. What is the best way to treat my fecal incontinence?
   
   
4. Will making dietary changes alone be enough to address my problem?
   
   
5. Do I have to stop drinking coffee, tea and soda?
   
   
6. Are there specific over-the-counter medications you would recommend for me?
   
   
7. Am I a candidate for a procedure to relieve fecal incontinence? If so, what are the risks and benefits?
   
   
8. When should I expect to see results from the treatment plan?
   
   
9. What conditions/changes should I contact you about prior to our next appointment?
   
   
10. Should I avoid having an episiotomy during childbirth?