Eliminating the Mystery about Elimination and Fecal Incontinence

Opening up about a problem is never easy—especially one as personal and potentially embarrassing as fecal incontinence or chronic constipation. But once you engage with your patients about the subject, a little education can go a long way to help them along the road to wellness. After all, knowledge is power. And most patients know very little, if anything, about these conditions.

First, helping patients understand that incontinence and constipation are symptoms—not diseases or diagnoses in their own right—is extremely important. These problems can result from a wide range of underlying issues, and every patient is unique. In fact, often an individual’s problems are driven by multiple factors.

The Basics: We all know that once we eat, digestion and the principles of motility, the peristaltic action of digestive tract muscles to move the waste material through into the rectum, is automatic. Your patients rarely know what happens next – that nerves on the rectal walls sense when the rectum fills with waste and that the inner anal sphincter relaxes to allow the stool to pass. Again, this is all supposed to be automatic. When the patient has a strong enough urge to defecate (based on the sensation from the rectal wall nerves), it’s finally up to them to relax their outer sphincter to allow the stool to pass when they are ready.

Fecal Incontinence

Fecal Incontinence (FI) affects over 20 million Americans. Generally, this ranges from occasional leakage while passing gas to a complete loss of bowel control. It so adversely impacts quality of life, roughly 28% of these people are homebound and it is the leading cause of entry into assisted living facilities and nursing homes. It is estimated that FI is associated with 55% higher health care costs for those suffering from this.

There are two primary types of fecal incontinence – Urge Incontinence occurs in people for whom the urge to defecate comes suddenly and cannot be stopped, and Passive Incontinence, when the person is unaware they need to pass stool.

So why might your patients suffer from fecal incontinence? As their physician, there are several possible diagnoses you may determine.

• Muscle damage to the anal sphincter may result in physical difficulty holding stool back. In women, these muscular rings at the end of the rectum may be damaged during childbirth, especially if forceps were used or an episiotomy was performed.
• Loss of rectal volume due to post-surgical scarring, radiation treatment, or inflammatory bowel disease may prevent the rectum from stretching normally to collect and store stool. This may cause stool to leak out.
• Damage to the rectal nerves that sense the presence of stool or that control the anal sphincter may prevent proper control. Such damage may be the result of spinal cord injury or stroke, childbirth, constant straining during bowel movements, and even diseases such as diabetes.
• Rectal prolapse, where the rectum drops into the anus, may stretch the sphincter damaging its nerves and its ability to function properly.
• Even the swelling of hemorrhoids may prevent the anus from completely closing, allowing stool to leak out.

It is important to assure your patient that fecal incontinence does not mean that someone is careless or lazy. Typically, it results from physical problems such as those we’ve just described above.

Many of the causes of defecation dysfunction can be addressed through physical therapy and retraining using biofeedback, while others require more invasive solutions. The good news for patients is that many fecal incontinence and related disorders can be corrected or controlled with appropriate interventions.

A simple Anorectal Manometry exam is often used to assess the ability of the rectum and anus to expand and contract, detect pressure and work together to eliminate stool. Anorectal Manometry can also be used as a biofeedback tool to help patients control their defecation urges as well as strengthen and retrain muscles to overcome many of these problems.

Oh No! . . . I Can’t Go – Explaining Muscle Control and Chronic Constipation takes a deeper dive into some of the specific problems that can cause defecation disorders and presents simplified information about these disorders that will help patients, their loved ones, and caregivers understand these problems.