Fecal incontinence

Did You Know?

• The rectoanal inhibitory reflex (RAIR) is an involuntary internal anal sphincter relaxation in response to rectal distension, allowing some rectal contents to descend into the anal canal.
• More than 50% of hospitalized seriously ill patients rated bladder or fecal incontinence as 'worse than death'.
• Some insults in Japan relate to incontinence, such as kusotare, though these have not been in common use since the 1980s.

Causes

Fecal incontinence is a symptom, not a disease itself, and can stem from many different underlying issues. It often arises from a mix of several factors working together, and many of these are straightforward to fix. In fact, up to 80% of people dealing with this condition have more than one contributing problem. The body can sometimes compensate for weaknesses in the continence system for a while, but eventually those backup systems may fail. The most common triggers are childbirth injuries and complications from anorectal surgeries, particularly those affecting the anal sphincters or hemorrhoidal cushions. Among adults over 18, most cases fall into categories like structural damage to the anus or rectum, neurological conditions (such as multiple sclerosis or stroke), severe constipation or stool buildup, cognitive or behavioral issues, diarrhea, inflammatory bowel diseases like Crohn’s or ulcerative colitis, irritable bowel syndrome, physical disability, or unknown causes. Diabetes is also linked to the condition, though exactly how remains unclear.

Diagnosis

To find the cause of fecal incontinence, doctors start with a detailed history covering symptoms, diet, medications, and bowel habits. A digital rectal exam checks resting pressure and the strength of a voluntary squeeze, and can reveal sphincter defects, rectal prolapse, or abnormal perineal descent. Anorectal physiology tests evaluate how the anus and rectum work. Anorectal manometry measures pressure from the sphincters and puborectalis at rest and during contraction, and also tests sensation in the anal canal and rectum. Anal electromyography looks for nerve damage, often from childbirth. Pudendal nerve terminal motor latency tests the pudendal motor nerves. Proctography, or defecography, shows how much stool the rectum can hold, how well it retains it, and how effectively it empties, while also spotting structural issues like internal rectal intussusception. Dynamic pelvic MRI is another option, better for some problems but not others. Proctosigmoidoscopy uses a flexible tube with a camera to view the anal canal, rectum, and sigmoid colon, checking for inflammation, tumors, or scar tissue. Endoanal ultrasound, often considered the best method for anal canal lesions, examines sphincter structure and can find hidden tears.

Management

Fecal incontinence can often be managed through conservative approaches, surgery, or a combination of both. How well treatment works depends on the underlying causes and whether they can be corrected. The choice of treatment is influenced by the cause, severity, the person’s motivation, and their overall health. Conservative methods are frequently used together, and surgery may be added if appropriate. These conservative options include changes to diet, medications, retrograde anal irrigation, biofeedback, and exercises for the anal sphincter. Incontinence products like anal plugs, perineal pads, and diapers are available, though pads are only effective for mild cases. If nothing else works, removing the entire colon or creating a colostomy might be considered. Dietary changes need to be tailored to the specific problem. For those with diarrhea or soft stools, helpful steps can include increasing fiber, cutting back on whole grains, certain fruits and vegetables like rhubarb and prunes, beans, cabbage, spices, caffeine, alcohol, artificial sweeteners, and lactose if there is a deficiency. Medications such as anti-diarrheals, constipating agents, laxatives, or stool bulking agents may be used, but there is no strong evidence supporting any of them.

Society and culture

Fecal incontinence is often hidden due to intense social stigma, with those affected frequently facing ridicule and exclusion. It is considered one of the most psychologically and socially damaging conditions for an otherwise healthy person. Among the elderly, it is a leading cause of nursing home admission. People who develop it earlier in life have lower rates of marriage and employment. Many go to extreme lengths to conceal the problem, earning it the nickname "the silent affliction," as it is rarely discussed with family, employers, or doctors. Sufferers may endure gossip and hostility. The financial burden is understudied, though in the U.S., the average lifetime cost per person was $17,166 in 1996, and surgical charges rose from $34 million in 1998 to $57.5 million in 2003. Passing gas with fecal leakage is colloquially called a "shart."