Fecal incontinence is a problem that is often not addressed, probably in no small part due to embarrassment on the part of the sufferer. Fecal incontinence is not rare. One study in 1996 from Illinois revealed that nearly 20% of individuals over 18 experience fecal incontinence. What are risk factors for fecal incontinence? In women, childbirth is a common cause of injury to the rectal sphincter. The sphincter may be damaged even without a tear occurring. Interestingly, sphincter damage alone does not always lead to fecal incontinence because there are several muscles in the pelvic floor that contribute to fecal continence. However, gas and liquid stool are typically more difficult to control than solid stool. Other risk factors may include nerve damage (traumatic, infectious, autoimmune, toxins, or other causes), declining mental function, fistulas (abnormal connections between the bowel and either the vagina, bladder, or perineum), tumors, prolapsed rectum, inflammatory bowel conditions, and immobility. Because every case is unique, the individual causes need to be determined in order to develop a reasonable treatment plan. It is most important to get a thorough evaluation and confront the problem before it becomes more difficult to manage. While many women are embarrassed by this problem, it is important to understand that treatment is available but can only be offered when the problem is brought to the doctor’s attention.
Whom to consult about fecal incontinence? A urogynecologist, colorectal surgeon, or gastroenterologist may be comfortable dealing with some or all causes of fecal incontinence. However, this should not deter a woman from bringing the subject up with her primary care provider. First line therapy may be instituted, or appropriate referrals generated after voicing the initial complaint. If no referrals or treatment plans are offered, seeking help from a qualified specialist is the next appropriate step.
What types of treatments are available? First line treatment in many cases will consist of pelvic floor physical therapy with appropriate dietary modification, sometimes with appropriate stool bulking agents or mildly constipating agents to change the consistency of the stool. Other practical modifications should also be explored when appropriate. For example, a person with limited mobility may find that making a toilet easier to access will help avoid accidents. In some cases, surgical treatments are appropriate. However, many types of fecal incontinence are not treated with major surgery. In fact, the longterm cure rates with sphincterplasty are poor, so other avenues are often best explored first. However, in the case of rectal prolapse (the tissue in the rectum actually protrudes through the opening and hangs out of the anus to varying degrees), surgical treatment is frequently needed. When the prolapse can not be reduced or does not retract on its own, the issue is more urgent and care should be sought without delay. Other types of procedures that can be used to treat fecal incontinence may include bulking procedures around the rectum with Solesta (R), which has been associated with greater than 50% improvement in bowel leakage episodes; the Secca (R) procedure (which involves heating and stiffening the collagen around the rectal canal with a special device), and the Interstim implant (a nerve stimulator similar to a pacemaker). There are newer, experimental procedures being worked on to improve the sphincter function or create an artificial sphincter. Thus far, there are no artificial anal sphincters approved for use in the US, but there are studies underway attempting to develop such a device. Most of the procedures which attempt to create a new sphincter by transpositioning muscles from another location have had less than satisfying results in long term studies, so are not commonly in use today. Determining the appropriate treatment and creating a treatment plan is extremely important, which is why seeing a specialist is vital when conservative measures don’t succeed.
What kind of tests are done? A thorough history and physical examination is critical in beginning the evaluation for fecal incontinence. After that, a symptom diary can be helpful. Defecography either with X-ray or MRI may be requested to further evaluate the problem.
If you need more information or an evaluation regarding this problem, consult your primary care physician or a specialist. For a consultation call 561-701-2841.
Linda Kiley, MD
Dr. Kiley is a Board Certified subspecialist in Female Pelvic Medicine and Reconstructive Surgery, and is also Board Certified in general Obstetrics and Gynecology.