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. Conditions that may cause fecal incontinence include constipation, diarrhea, muscle damage, nerve damage and pelvic floor dysfunction. When it occurs in children under age 4, it is most commonly the result of constipation caused by withholding stool, and is known as encopresis.

To determine the cause of fecal incontinence, a physician will perform a physical examination, which may include a digital rectal examination (DRE) or an anal wink test. Other diagnostic tests that may be performed include 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, medications 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 is defined as continuous or recurrent loss of fecal material in individuals over 4 years of age. It results in the involuntary release of stool 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 at the mouth and exits at the anus. Most nutrients are absorbed from food as it travels through the small intestine. Most water and salt are absorbed by the body during transport through the large intestine. 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. The buildup of stool in the rectum triggers the surrounding muscles to tighten the anal sphincter (rings of muscles at the end of the rectum that hold in stool). Stool usually remains 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 a person is ready to have a bowel movement. Fecal incontinence may occur when the:

• 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 (pruritus ani). Such anal discomfort 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 how many people 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.

Fecal incontinence can occur in children for a number of different reasons, including birth defects or disease. However, the most common cause of fecal incontinence among children is chronic constipation.

Children who are already toilet trained often become constipated because they avoid having bowel movements. When stool is retained, it leads to the buildup of dry, hard stool in the rectum. Liquid stool may then be involuntarily released around the hard, impacted stool (fecal impaction) still inside the rectum. When this occurs in children as the result of withholding stool, it is called encopresis.

Warning signs of encopresis include:

• Fecal stains on underwear
  
• Refusal to go to the bathroom
  
• Squatting, crossing legs or rocking (to hold back a bowel movement)
  
• Pain with bowel movements
  
• Hard, dry stool
  
• Unable to eat much, despite feelings of hunger

Children may withhold their stool for any number of reasons. These include psychological reasons (e.g., stress, embarrassment, fear of unfamiliar settings) and physical concerns (e.g., to avoid pain associated with passing hard, dry stool). They may also be unwilling to use public toilets or to stop playing in order to have a bowel movement.

Repeated delay or withholding of bowel movements can cause a child to lose the sense of urgency that triggers the need to defecate. This can lead to constipation and fecal incontinence.

Treatment of fecal incontinence in children is similar to that for adults. The first step is to consult a physician who may identify the cause of the incontinence. Medication may be necessary to resolve the underlying constipation or fecal impaction. Bowel training and diet modification may also be necessary to prevent future episodes of constipation or fecal incontinence.

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 or the inability to pass stool. This is one of the most common causes of fecal incontinence. Chronic constipation stretches the muscles of the rectum (making them less able to hold stool) and weakens the nerves of the rectum and anus (making them less responsive to the presence of stool in the rectum). Constipation may also cause stool to become stuck in the rectum (fecal impaction). When liquid stool flows around the impacted stool and is involuntarily released through the anus, it is sometimes mistaken for diarrhea, although it is really the result of constipation. When this type of involuntary leakage occurs in children who withhold their stool, it is known as encopresis.
  
  
• Diarrhea. Loose or watery stool. When stool is liquid or watery, it is more difficult to contain in the rectum. Thus, fecal incontinence can occur as a result of diarrhea. Conditions such as inflammatory bowel disease (IBD) (e.g., Crohn’s disease, ulcerative colitis) may cause diarrhea that can lead to fecal incontinence. Irritable bowel syndrome (IBS) can cause both diarrhea and constipation, increasing a patient’s risk of fecal 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. Research also indicates that women who have had numerous vaginal deliveries are more likely to experience fecal incontinence. Hysterectomy (surgical removal of the uterus) may also increase the risk of the condition in women.
  
  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. Scarring of rectal tissue can make rectum walls stiff and unable to stretch adequately enough to hold stool. Rectal surgery, radiation treatment and inflammatory bowel disease (IBD) can all cause rectal scarring. IBD can also 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. 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 (protrusion of the rectum through the anus)
    
  • Rectocele (protrusion of the rectum through the vagina)
    
  • Generalized weakness and sagging of the pelvic floor
    
    
• Urinary incontinence. Research shows a link between urinary incontinence (the inability to control the passage of urine) and fecal incontinence in women.
  
  
• Unknown. 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 the cause of fecal incontinence is a physical examination and medical history that includes a description of symptoms and list of all current medications. A physician will visually inspect the anus and perineum (area between the anus and genitals) for conditions that may cause fecal incontinence.

A physician may also use a prodding device or probe to gently 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 examination (DRE), which involves inserting a gloved and lubricated finger into the rectum. This is used to check for any abnormalities and to evaluate sphincter muscle strength.

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

• Fecal tests. Laboratory examination of a sample of stool. 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. The use of sound waves to produce images of anal and rectal areas. A narrow, wand-like instrument that emits sound waves is inserted into the anus and rectum. Images are then produced on a computer screen for examination by a physician. This test can reveal structural abnormalities of the anal sphincters, rectal wall and the pelvic muscles that help maintain continence.
  
  
• Defecography. 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.
  
  
• Sigmoidoscopy. A flexible tube with camera and light attached are inserted in the anus and through the rectum and sigmoid colon (the last two feet of the colon). Tissue samples may be removed for analysis under a microscope. This test is used to detect signs of inflammation, tumors or scar tissue that may cause fecal incontinence.
  
  
• Colonoscopy. Similar to a sigmoidoscopy, except that the tube is inserted farther up the digestive tract, allowing examination of the entire large intestine.
  
  
• Anoscopy. A direct visual examine of the anus, anal canal and lower rectum by a physician using a special instrument (anoscope) that is lubricated and inserted a few inches into the rectum. The test is used to identify hemorrhoids, polyps, inflammation or other possible causes of fecal incontinence.
  
  
• Anal electromyography. Detects nerve damage or muscular causes of 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.

Patients may be treated by the following types of physicians who specialize in conditions that affect the colon, rectum and anus:

• Gastroenterologists. Physicians specializing in the diagnosis and treatment of diseases of the digestive tract.
  
  
• Proctologists. Physicians specializing in diseases of the colon, rectum and anus.
  
  
• Colorectal surgeons. Physicians specializing in the diagnosis and surgical treatment of benign (noncancerous) 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 or surgery. In cases where fecal impaction (due to constipation) is the cause of incontinence, a physician may need to first manually break up the hardened stool by inserting a lubricated, gloved finger into the rectum.

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 incontinence related to diarrhea or constipation. Recommended diet modification techniques include:

• Keep 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, indicating certain foods that may be troublesome and should be avoided.
  
  
• Eat small, frequent meals. Large meals cause bowel contractions in some people, speeding digestion and causing diarrhea. Eating six small meals a day instead of three large ones may reduce fecal incontinence.
  
  
• Drink plenty of fluids. Drinking eight 8-ounce glasses of water a day prevents dehydration and keeps stool soft and formed. Drinks with alcohol, milk or carbonation should be avoided since they may cause diarrhea and fecal incontinence.
  
  
• Separate eating and drinking. Liquid helps move food through the digestive system, which may cause diarrhea. To slow the process, drink fluids a half hour before meals and avoid fluid consumption while eating.
  
  
• Consume 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.
  
  
• Avoid caffeine. Beverages and food containing caffeine (e.g., coffee, tea, soft drinks, 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 include:

• Bulking agents. A type of laxative that increases fecal volume, making stool easier to control and stimulating bowel movements. Bulking agents 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.
  
  
• Antispasmodics. Medications that reduce the spontaneous motions of the bowels.
  
  
• Antidiarrheals. Medications that slow digestion, helping to prevent diarrhea.

Bowel training can help some people manage fecal incontinence. This may involve muscle strengthening or training the bowel to empty at a specific time during the day. Bowel training techniques include:

• 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. 

Recent research also shows that sacral nerve stimulation may be very effective in relieving fecal incontinence. This procedure involves the implantation of an electrical device which sends signals to nerves that are connected to the lower back.

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

• Sphincteroplasty. Surgical repair of damaged or weakened sphincter muscles. Sphincter muscles are tightened by reinforcing the edges of injured muscle tissue. This type of surgery is effective for patients with sphincter muscle damage in a single location.
  
  
• Repair of complications that result from damaged pelvic floor muscles. When the rectum extends through the anus (rectal prolapse), it can weaken the anal sphincter muscles and cause fecal incontinence. Protrusion of the rectum into the vaginal wall (rectocele) may also cause fecal incontinence. Surgery to repair rectal prolapse or rectocele can correct incontinence. Sphincteroplasty may also be necessary to repair weakened sphincter muscles.
  
  
• Hemorrhoid surgery. 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). The presence of internal hemorrhoids can lead to failure of the anal sphincter to close properly, which can lead to fecal incontinence.
  
  
• Sphincter replacement. An inflatable device (artificial anal sphincter) is implanted around the anal canal. As long as the device is inflated, the anal sphincter remains closed to retain stool. Patients may temporarily deflate the device (using a small external pump) to release stool.
  
  
• Gracilis muscle transplant. Surgical repair of the anal sphincter to restore muscle tone. Tissue is taken from another part of the patient’s body (the inner thigh) and is used to strengthen the anal 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 the sacral nerves involved in bowel and anal sphincter control. Through the wire, the device emits electrical pulses that control bowel and anal sphincter functioning. This procedure may help eliminate fecal incontinence due to nerve damage.
  
  
• Colostomy. Surgery in which the normal process of stool is diverted so that it exits the body through an opening in the abdomen instead of through the anus. A special bag (colostomy bag) is attached to the abdomen to collect 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, which can worsen irritation.
  
  
• 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 the 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.

Fecal incontinence may be prevented when its cause can be prevented. Some prevention techniques include:

• Reducing constipation. When fecal incontinence is due to chronic constipation, the incontinence can be reduced or eliminated by treating the constipation. Tips include getting more exercise, consuming adequate amounts of fiber and drinking plenty of fluids. Taking fiber supplements may also reduce constipation.
  
  
• Avoid straining. Straining to defecate may weaken anal sphincter nerves and muscles, which can lead to fecal incontinence.
  
  
• 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 (sweetener used in diet foods). Avoiding caffeinated foods and drinks may also help control diarrhea.

Patients prone to constipation or diarrhea should see a physician to determine if an underlying medical condition or disease is responsible for the constipation or diarrhea. Early detection and treatment of any such problem can prevent constipation or diarrhea that may lead to fecal incontinence.

People who experience fecal incontinence may be reluctant to seek help. Losing control of bowel movements can restrict activities and cause emotional distress (e.g., shame, embarrassment, isolation, depression).

Even so, consulting a physician is very important. A physician may be able to identify the cause of fecal incontinence and recommend treatment options. In most cases, treatment provides relief from fecal incontinence.

In cases where complete relief is not possible, it may be important for patients with fecal incontinence to seek emotional support to reduce stress levels and better manage their incontinence. Additional coping tips include:

• Keep cleanup supplies and extra underwear handy
• Know where restrooms are located when traveling
• Use the toilet before leaving the house
• Use disposable undergarments if necessary
• Wear clothing that can be easily removed
• Use fecal deodorants (taken orally) if necessary
• Place washable pads or covers on furniture
• Keep a bed pan near the bed

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

1. What is causing my fecal incontinence?
   
   
2. If I am experiencing fecal incontinence, will I also experience urinary incontinence?
   
   
3. Do I have an underlying condition that is causing or contributing to my fecal incontinence?
   
   
4. What is the best way to treat my fecal incontinence?
   
   
5. Will making dietary changes alone be enough to address my problem?
   
   
6. Do I have to stop drinking coffee, tea and soda?
   
   
7. Are there medications that can help reduce my symptoms? What are their side effects?
   
   
8. Are there specific over-the-counter (OTC) medications you would recommend for me?
   
   
9. Are there specific OTC or prescription medications I should avoid?
   
   
10. Am I a candidate for a procedure to relieve fecal incontinence? If so, what are the risks and benefits?
    
    
11. When can I expect to see results from my treatment plan?
    
    
12. What conditions/changes should I contact you about prior to my next appointment?