Bowel Incontinence

The loss of bowel control, or bowel incontinence, affects up to 10 percent of adults, the majority of whom are women. Despite its prevalence, many women do not seek treatment, either because they are embarrassed to ask for help or just don’t realize that it can be effectively treated. Many women resort to altering their social and physical activities, even their employment, to cope with the problem.

Although these are sobering statistics, the total picture is far more positive. With appropriate treatment, most patients with bowel incontinence can be cured or significantly improved and can return to a better quality of life.

Causes
Normal control of bowel movements depends on proper functioning of the brain and nervous system, the colon, the rectum and the muscles surrounding the anus, and on the amount and consistency of waste products produced. The most common cause of bowel incontinence in otherwise healthy women is an injury to the muscles surrounding the anus during childbirth. However, certain medications, trauma, diabetes, stroke, and other problems in both men and women can contribute to the loss of control.

There are two main types of bowel incontinence:

• Passive fecal incontinence is related to a poorly functioning sphincter muscle, and the person is unaware that stool is being passed.
• Urge incontinence is often caused by disease in the rectum, and results in involuntary passage of stool through normal sphincter muscles.

Evaluation and Diagnosis
Thorough evaluation and accurate diagnosis is critical to receiving the most appropriate treatment. Advanced, sophisticated diagnostic techniques have led to improved treatment. The following are a few of the tests available at the Cleveland Clinic:

• Endosonography, also called rectal ultrasound, is a new diagnostic tool that makes it possible to visualize the sphincter muscles by using sound wave to produce images and precisely identify abnormalities.
• Flexible sigmoidoscopy, a method of examining the inside of the lowest part of the colon using a thin, flexible, lighted tube called an endoscope.
• Manometry, a procedure to measure the pressure of the anal muscles.
• Nerve studies, tests to check for nerve damage.

Treatment
Treatment of incontinence can often involve more than one type of medical specialty, such as gastroenterology, gynecology and colorectal surgery, as well as physical therapy. For this reason finding a medical center with a multidisciplinary team of physicians who work together to treat incontinence is important. In a multidisciplinary environment, team members consult, discuss and agree upon the diagnosis, and together determine the most appropriate treatment for each patient.

Nonsurgical Therapy
Because incontinence is a symptom and not a disease, the method of treatment depends on diagnostic results. Sometimes simple changes in diet or the elimination of medications can cure incontinence. More frequently, treatment involves a combination of medicine, biofeedback and exercise.

Usually people are incontinent only when they have loose or liquid stools. The first step, therefore is to try to make the stools more solid and easier to hold. A fiber supplement, like Metamucil, can be quite helpful. Most people think that fiber is only a laxative, but it is also used to absorb the water in the stool. Antidiarrheal agents, such as Imodium AD and Lomotil, can be added to make the stools harder.

Muscle strengthening exercises (called Kegel maneuvers) can be very helpful. The muscles of the anus, buttocks, and pelvis should be contracted for five seconds as hard as possible, then relaxed. A series of 30 of these should be done three times per day. In a few weeks the pelvic muscles will be stronger and often the incontinence is improved or resolves.

Sometimes biofeedback training is needed. This involves putting a pressure probe in the anus or a sensing electrode on the skin. These are attached to a visual or sound display to tell the patient when the proper muscles are being used. Biofeedback helps improve the strength and coordination of the pelvic floor muscles and heightens the sensation related to the rectum filling with stool.

Patients who continue to experience bowel incontinence despite medical management may require surgery to regain control. This may be the case when anal muscle injuries have occurred (e.g. when the muscle is torn when a woman delivers a baby).

Surgical Options

• Rectal sphincter repair, called a sphincteroplasty, is the most common procedure used to correct a defect in the sphincter muscles.
• Muscle transposition is an option for a small percentage of patients whose condition cannot be successfully treated with sphincteroplasty. It involves using gluteal (buttock) or leg muscles to encircle the anal canal.
• A number of new surgical procedures are currently being investigated at the Cleveland Clinic. One recent study aims at demonstrating and defining the forms of anal sphincter and pelvic floor dysfunction associated with childbirth for earlier and more successful intervention.
• In rare and very difficult cases the only alternative may be a colostomy (a surgically created opening in the abdomen wall through which the colon passes, and where a bag is fitted to collect stool).